Medical Hearings Representative (Compliance Specialist 3)

  • Oregon Health Authority
  • Jun 12, 2019
Full time Compliance

Job Description

To be considered for this position you must apply at the following:

Do you have experience reviewing compliance, conducting investigations and writing reports?  Is your background in case hearing?  Have you worked in a medical/clinical environment?

The Oregon Health Authority – Health Systems Division is currently seeking a Medical Hearings Representative (Compliance Specialist 3) to join their team in Salem, Oregon.  This position represents the unit in contested case hearings regarding the denial of medical services by preparing, coordinating and presenting.  Additionally, it is responsible for ensuring compliance by the managed care plans with applicable federal and state rules and regulations.

What you will do!
You will review, research, and analyze complex medical data and decision notices to ensure Oregon Health Plan medical service denials are appropriate and in compliance with federal laws, state rules, regulations, contracts and agency policies. You are responsible for explaining to each claimant in understandable language the technical and legal material and ensure they understand the action subject to the hearing request.

You will write summaries to explain the facts and policy issues for contested cases.  You will present arguments in hearings regarding facts and application of facts to the rules, policies and laws.

What we are looking for!

  • Five years of experience doing administrative research that included compiling and evaluating facts to recommend management action or decide compliance with program guidelines and regulations. Three of the five years must be above the technical support level;
  • Experience related to a health plan’s grievance, appeal or hearing process;
  • Experience reviewing, researching and analyzing complex clinical information;
  • Experience understanding and interpreting federal and state rules and regulations;
  • Experience in advancing health equity, addressing systemic health disparities and collaborating with diverse, vulnerable and underrepresented populations.


Regulatory-Compliance Law