Providence Health & Services Managed Care Client Organization Representative (MCO) 2 PSJH in Beaverton, Oregon
Providence St. Joseph Health is calling a Managed Care Organization Representative (MCO) 2 to our location in Beaverton, OR.
We are seeking a Managed Care Organization Representative (MCO) 2 to act as a resource to program participants and monitors provider and payer compliance to workers' compensation MCO rules and contract requirements.The MCO Representative II evaluates and coordinates medical treatment reviews to reduce the number of time loss days and to assure that a proactive medical approach associated with treating injured workers occurs.
This position also provides advanced problem solving through the dispute resolution process with a diverse client population. This position must maintain supportive interpersonal relationships with all clients and with team members and also contributes to the team's planning and organization efforts. This position is responsible for providing all customer service needs, for updating all operations materials and overseeing the accuracy of all information utilized by MCO clients.
To understand, apply and teach workers' compensation medical, administrative, and MCO rules during the day to day operations, to office staff and MCO clients.
To promote and maintain good working relationships with providers, employers, insurers, and injured workers through client education and problem solving.
To reduce time loss by identifying modified work and coordinating a release with the attending physician.
To oversee the Dispute Resolution process and to process all issues fairly and within the Team Mission.
To promote cost effective medical care by facilitating physician compliance with the MCO treatment guidelines and contract requirements.
To develop and update the client operations manual, provide necessary operations training to claims adjusters and monitor program compliance according to OARs and MCO Contract.
To actively participate in total quality improvement and team management process.
To establish positive relationships with other departments that will enhance our customer service delivery.
To actively look for opportunities to promote Providence Health System and the MCO.
To provide timely communications to clients about changes in state rule requirements, provider changes, or program design.
Patient Population Served: Not Applicable.
In this position you will have the following responsibilities:
Acts as a resource to employers, insurers, medical providers, and injured workers to explain the program requirements, MCO rules, and general questions concerning the workers’ compensation system.
Monitors provider compliance to the MCO contract, the workers’ compensation medical and MCO rules, and the MCO treatment guidelines. Makes necessary interventions with providers and clients through education, problem-solving or referral to the MCO Associate Medical Director. Negotiates medical or administrative disputes with providers.
Coordinates the Dispute Resolution Program involving payers, employers, physicians, and workers. Interacts with DCBS when necessary. Prepares legal files for contested case hearings and staffs legal cases with MCO attorney. Writes litigation reports for enrollment disputes appealed to DCBS.
Provides all new client orientations and training. Provides direct training to assigned claims personnel or employers on a regular basis to insure compliance and conformance to program regulations.
Acts as customer service resource for assigned clients, injured workers or their representatives, interested parties and participating providers. Develops customer service plan for each assigned account. Meets all customer service standards.
Provides effective medical and administrative problem solving and negotiation for program operations, dispute resolution, and medical treatment reviews.
Acts as a technical resource for providers for workers’ compensation issues and strategies.
Maintains client operations files and inputs timely updates to the informational data base. Develops and implements strategy for increasing enrollment and program utilization or resolving payment issues.
Required qualifications for this position include:
Coursework/Training or College Degree or equivalent educ/experience.
Combination of college courses and relevant work experience.
At least 2 years in experience with computer software applications.
At least 2 years in claims adjusting experience in workers’ compensation field.
Must demonstrate ability to communicate effectively with medical professionals, insurance carriers, and employers.
Excellent phone skills and problem solving ability are essential.
Ability to give effective group presentations and product training to clients and providers.
Ability to translate workers’ compensation rules into policy and procedure and daily application.
Must have knowledge of medical terminology, disease specific treatment plans, and medical reports and be able to effectively provide focused medical case management.
Must be resourceful and have the judgment and confidence to work independently, manage time efficiently, delegate appropriately and handle multiple priorities and projects.
Must demonstrate ability to effectively communicate with a diverse client base and must be able to communicate with angry people effectively.
Must be able to work in a team oriented setting.
Must demonstrate knowledge and application of medical and claims management.
Must demonstrate the ability to develop and maintain professional relationships with payers, providers, employers, and regulatory staff.
Must be able to work flexible hours when needed.
Must demonstrate competency in medical terminology and medical claims management.
State of Oregon Claims Adjusting Certificate.
Must have a valid unencumbered drivers license.
About the department you will serve.
Providence Strategic and Management Services provides a variety of functional and system support services for all eight regions of Providence Health & Services from Alaska to California. We are focused on supporting our Mission by delivering a robust foundation of services and sharing of specialized expertise.
We offer a full comprehensive range of benefits - see our website for details
As expressions of God’s healing love, witnessed through the ministry of Jesus, we are steadfast in serving all, especially those who are poor and vulnerable.
Providence Health & Services is a not-for-profit Catholic network of hospitals, care centers, health plans, physicians, clinics, home health care and services guided by a Mission of caring the Sisters of Providence began over 160 years ago. Providence is proud to be an Equal Opportunity Employer. Providence does not discriminate on the basis of race, color, gender, disability, veteran, military status, religion, age, creed, national origin, sexual identity or expression, sexual orientation, marital status, genetic information, or any other basis prohibited by local, state, or federal law.
Job Category: Analytics/Business Intelligence
Req ID: 241719