Medical Hearings Representative (Compliance Specialist 3)

The primary purpose of this position is to represent Medicaid Division in contested case hearings regarding the Medicaid service denials of medical, dental, and behavioral health services; and to resolve difficult issues that could set a precedence, ultimately impacting the ability to rely on the Oregon Administrative Rules to support coverage determinations. Issues may be a result of compliance, rule application, etc.

The person in this position will review, research, and analyze complex medical records, various data sources including health studies, medical journal articles and other resources, often with conflicting information, to assure the service was denied appropriately in compliance with federal laws, state rules, regulations, contracts and agency policies. In addition, this position will research laws, case precedent and legislative intent to provide technical assistance, guidance and training to OHP members, OHA contracted plans, attorneys, DHS/OHA staff and providers concerning interpretation of statutes and rules, content and application of case precedent, and to formulate policy recommendations.

This position will factor in the perspectives of diverse populations most harmed by social injustice and inequities including communities of color, immigrant groups, the disability and neurodivergent communities, veterans, older adults, individuals identifying as LGBTQIA+ and other communities that have been traditionally marginalized.

• This announcement is for one full-time, permanent, SEIU (union) represented, Compliance Specialist 3 position based in Salem, Oregon.
• This is a HYBRID (35% IN-OFFICE) position. Please check SECTION 4. WORKING CONDITIONS, of the position description linked above to review more details regarding the details surrounding the working conditions.

Minimum Qualifications:

Five years experience doing administrative research that included compiling and evaluating facts to recommend management action, or decide compliance or eligibility with program guidelines and regulations.

Three of the five years must be above the technical support level.

College-level course work may substitute for experience on the basis of 45-quarter units per year, up to a maximum of three years.

Desired Attributes:  

• Experience supporting the development and implementation of policies and programs at the community, state, and/or national level that advance health equity (address systemic health disparities, expand culturally responsive and inclusive services, factor in social determinants of health) and elevate the voice of community and those with lived experience.
• Knowledge of health services delivery systems, particularly the Oregon Health Plan/ Medicaid administration in Oregon and relational landscape of key partners, providers, community based organizations, and advocacy groups.
• Knowledge of legislative and regulatory processes; specific knowledge of Oregon Administrative Rules, Oregon Revised Statutes, and federal and state Medicaid laws and regulations is valued.
• Ability to research laws, case precedent and legislative intent concerning interpretation of statutes and rules, content and application of case precedent, and to formulate policy recommendations.
• Knowledge of quality assurance and continuous process improvement procedures including experience support for compliance monitoring.  
• Experience analyzing, researching, and drafting legal documents, and presenting and articulating the value and relevance of research, evaluation data, and evidence; specific experience planning case theory, performing case presentation, or supporting administrative hearings is valued.
• 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, verbal and written, that are accessible to and understood by audiences with different levels of comprehension or interest and that are culturally responsive, inclusive, and appropriate.

Benefits of Joining Our Team

• Excellent medical, vision, and dental benefits package for the employee and qualified family members with a very low monthly out-of-pocket cost.
• Optional life insurance, short-term disability, long-term disability, deferred compensation savings program, and flexible spending accounts for health care and childcare expenses.
• Employee benefits include 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 that will help grow your career with the State of Oregon.

How to Apply: Submit your resume and cover letter to Oregonjobs.org using job number REQ-182176

Application Deadline:  06/23/2025

Salary Range:  $5,842 - $8,967

https://oregon.wd5.myworkdayjobs.com/SOR_External_Career_Site/job/Salem--OHA--Summer-Street/Medical-Hearings-Representative--Compliance-Specialist-3-_REQ-182176