The Oregon Department of Human Services is hiring a Medical Hearings Representative (a Compliance Specialist 3 with CS2 underfill opportunity). In this role, you will represent the Medicaid Division in contested case hearings regarding Medicaid service denials. You’ll review, research, and analyze complex medical records and data to ensure denials comply with laws and rules, while researching case precedent to provide technical guidance and training.
What You'll Do
- Represent the Medicaid Division in contested case hearings regarding denials of medical, dental, and behavioral health services.
- Resolve difficult issues that could set precedence impacting the ability to rely on Oregon Administrative Rules.
- Review, research, and analyze complex medical records, health studies, and medical journal articles to assure service denials were appropriate.
- Research laws, case precedent, and legislative intent to provide technical assistance, guidance, and training to OHP members, OHA contracted plans, attorneys, staff, and providers.
- Factor in the perspectives of diverse populations most harmed by social injustice and inequities.
- Formulate policy recommendations.
What We're Looking For
- For Compliance Specialist 3: Five years of experience doing administrative research that included compiling and evaluating facts to recommend management action or decide compliance or eligibility with program guidelines and regulations.
- For Compliance Specialist 3: Three of the five years must be above the technical support level.
- For Compliance Specialist 2 (underfill): Four years of experience doing administrative research that included compiling and evaluating facts to recommend management action or decide compliance with program guidelines and regulations.
- For Compliance Specialist 2 (underfill): Two of the four years must be above the technical support level.
Nice to Have
- Experience supporting the development and implementation of policies and programs that advance health equity.
- Knowledge of health services delivery systems, particularly the Oregon Health Plan/Medicaid administration in Oregon.
- Knowledge of legislative and regulatory processes; specific knowledge of Oregon Administrative Rules, Oregon Revised Statutes, and federal and state Medicaid laws and regulations.
- Ability to research laws, case precedent and legislative intent concerning interpretation of statutes and rules.
- Knowledge of quality assurance and continuous process improvement procedures including experience support for compliance monitoring.
- Experience analyzing, researching, and drafting legal documents, and presenting research and evidence; specific experience planning case theory, performing case presentation, or supporting administrative hearings.
- Knowledge of the International Classification of Disease Codes, and familiarity with current medical and dental terminology.
- Strong oral and written communication skills across a variety of forums; experience communicating qualitative and quantitative information that is culturally responsive and inclusive.
Benefits & Compensation
- Salary: Compliance Specialist 3: $5,842 - $8,967 per month. Compliance Specialist 2 (underfill): $4,833 - $7,407 per month.
- Excellent medical, vision, and dental benefits package for the employee and qualified family members with low monthly out-of-pocket cost.
- Optional life insurance, short-term disability, long-term disability, deferred compensation savings program, and flexible spending accounts.
- 11 paid holidays, 3 personal business days, 8 hours of monthly sick leave, and vacation accrual starting at 8 hours per month.
- Possible eligibility for the Public Service Loan Forgiveness Program.
- Membership in the Public Employees Retirement System (PERS)/Oregon Public Service Retirement Plan (OPSRP).
- Training opportunities.
Work Mode
This is a hybrid position based in Salem, Oregon.
The Oregon Health Authority is an affirmative action and equal opportunity employer, committed to fair employment practices and pay equity for all employees.
