Jobs at CareOregon

Supports members, providers, and pharmacies with pharmacy benefit questions, claims processing, prior authorizations, formulary exceptions, appeals, and grievances. Verifies eligibility, reviews medication histories, documents activities, performs data entry, communicates coverage decisions, and assists with pharmacy benefit projects and process improvements. Requires pharmacy or health plan experience, managed care or pharmacy benefit management experience, pharmaceutical terminology knowledge, and strong customer service and communication skills. This is a work-from-home role with occasional travel.

Serves as the primary finance advisor to business leaders, integrating financial and operational data to explain trends, risks, and variances. Supports forecasting, budgeting, planning, and performance analysis while translating results into actionable recommendations. Builds cross-functional relationships, promotes financial literacy, and partners with FP&A, Accounting, Actuarial Services, and operational teams. Provides coaching to analysts and junior finance partners and represents Finance in external forums as needed.

Coordinates community outreach, engagement, partnerships, public participation, health education, events, and small improvement projects. Builds relationships with community-based organizations, supports health equity initiatives, facilitates workgroups, develops communication materials, and represents CareOregon at community events. The role also manages project plans, stakeholder communications, reporting, and contract administration while serving vulnerable and diverse populations.

Lead large-scale projects, programs, and process improvements using project/program management, change management, and Lean principles. Develop plans, manage stakeholders and resources, monitor status, budgets and compliance, deliver training, mentor staff, and ensure successful implementation and documentation across health plan systems.

Designs, implements, maintains, and improves corporate information security technologies, including firewalls, proxies, logging, IDS/IPS, and related systems. Evaluates security risks, recommends solutions, develops policies and standards, monitors system performance and anomalies, supports disaster recovery, documents systems, and coordinates vendors and service agreements. The role also consults with IS teams, supports security projects, and contributes to compliance and governance initiatives.

Leads quality assurance for clinical systems and utilization management decision tools. Oversees teams, training, clinical content testing, regulatory compliance, audits, reporting, remediation, and process improvement. Collaborates with Clinical Operations, Medical Directors, vendors, and other departments to ensure Medicare and Medicaid requirements are met. Manages staffing, performance, project plans, workflows, and quality initiatives, including root cause analysis and change management. This remote role requires an Oregon RN license and substantial health plan quality operations experience.

Manage actuarial analysis for financial reporting, including IBNR and PDR estimates, trend forecasting, cost/utilization modeling, ROI evaluation, regulatory reporting, and leading a team. Partner with finance and business leaders to communicate results, drive data-driven decisions, and ensure timely regulatory submissions.

Lead large, complex technology-focused projects using project management and LEAN principles across the full lifecycle. Scope, plan, manage implementation, drive stakeholder consensus, ensure compliance, manage budgets, apply change management, maintain documentation, and support post-implementation evaluation for enterprise-wide initiatives.

Investigates and audits healthcare claims to identify overpayments, execute recovery strategies, and improve payment integrity. Reviews CMS and RAC topics, validates vendor recovery recommendations, researches regulations and billing guidelines, documents root causes, prepares provider notifications, processes claims adjustments, resolves disputes, and supports testing. The role collaborates with clinical, finance, claims, contracting, configuration, provider relations, vendors, and other internal partners while meeting productivity, quality, and savings goals.

Leads and grows a customer-centered Finance organization overseeing accounting, reporting, planning, actuarial analysis, rate development, risk adjustment, revenue, and procurement. Provides strategic financial leadership for Medicaid and Medicare operations, budgeting, forecasting, regulatory compliance, investments, partnerships, and organizational planning. Advises executive leadership, manages stakeholder relationships, sponsors key initiatives, and develops high-performing teams through hiring, coaching, performance management, and continuous improvement.

Perform QA reviews of HRSN/rent-assistance benefit allocations, validate documentation and calculations, analyze trends, prepare reports for leadership and OHA, support audits and corrective actions, provide data entry and accounting support, maintain records, and develop training and process improvements. Use Office, SharePoint, Workday, and Unite Us; collaborate with cross-functional teams to ensure compliance and program quality.

Lead enterprise provider data management and credentialing operations for Medicaid and Medicare lines, ensuring compliant, accurate provider data, optimized systems, strategic network development, resource and budget management, process improvement, and team leadership to meet regulatory and organizational objectives.