Providence Health & Services Representative 2 - Managed Care Organization (MCO) in Beaverton, Oregon
Providence St. Joseph Health is calling a Representative 2 - Managed Care Organization (MCO) to Murray Business Center in Beaverton, OR.
We are seeking a Rep-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.
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.
Required qualifications for this position include:
College Degree or combination of college courses and relevant work experience.
2 years’ experience with computer software applications.
2 years claims adjusting experience in workers’ compensation field.
Must demonstrate competency in medical terminology and medical claims management.
State of Oregon Claims Adjusting Certificate.
Must have a valid unencumbered driver’s license.
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 be able to uphold the Mission of Providence Health System by representing the organization professionally and with integrity.
About the department you will serve.
As the largest healthcare system and largest private employer in Oregon, Providence offers exceptional work environments and unparalleled career opportunities.
The Providence Experience begins each time our patients or their families have an encounter with a Providence team member and continues throughout their visit or stay. Whether you provide direct or indirect patient care, we want our patients to feel that they are in a welcoming place where they can be comfortable and free from anxiety. Our employees create the Providence Experience through simple, caring behaviors such as acknowledging and welcoming each visitor, introducing ourselves and Providence, addressing people by name, providing the duration of estimated wait times and updating frequently if timelines change, explaining situations in a way that puts patients at ease, carefully listening to their concerns, and always thanking people for trusting Providence for their healthcare needs. At Providence, our quality vision is simple, "Providence will provide the best care and service to every person, every time."
Providence is consistently ranked among the top 100 companies to work for in Oregon. It is also home to two of our award-winning Magnet medical centers. Providence hospitals and clinics are located in numerous areas, ranging from the Columbia Gorge to the wine country to sunny southern Oregon to charming coastal communities to the urban setting of Portland. If you want a vibrant lifestyle while working with a team highly committed to the art of healing, choose from our many options in Oregon.
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: Healthcare Support
Req ID: 209765