Working Each Day to Make a Difference
At Community Health Plan of Washington, we’re driven by our belief that everyone deserves access to quality health care.
More than 25 years ago, we made a commitment to improve the health of our communities by making quality health care accessible to all Washington state residents.
We continue that pledge today by providing affordable comprehensive coverage to more than 315,000 individuals and families throughout the state.
- We are a local not-for-profit health plan in Washington State.
- We are committed to keeping Washington families healthy.
- We connect our communities to the health resources they need.
- We provide access to high-quality care for our members.
- We connect and empower our members through technology.
- The Community Health Centers we partner with strive to support members with a comprehensive mix of medical resources in one convenient location.
- Our partnerships with Community Health Centers and our extended provider network help us improve the health care delivery system.
To learn more about how you can make a difference working at Community Health Plan of Washington, visitwww.chpw.org.
Behavioral Health Utilization Management Clinician I
This position is available remotely in WA, OR, ID, TX, and FL.
POSITION PURPOSE:
Performs utilization review for medical or behavioral health requests using utilization review criteria, technologies and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient’s condition. Supports physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes. Ensures members have timely access to care and supports during transitions between levels of care. Understands and effectively communicates requirements and follows Community Health Plan of Washington (CHPW) policies and procedures.
PRINCIPAL DUTIES:
- Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies
- Collaborate with facilities to perform discharge planning
- Provide coordination support to members transitioning between care settings or returning home from a hospitalization. Identifies member needs and provides support to ensure necessary services are available during the transition period.
- Collaborates with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes
- Identifies, coordinates, and ensures high quality care and appropriate care by focusing on supporting access to care and services across the continuum of care in accordance with the patient’s medical needs
- Identify potentially unnecessary services and/or delivery settings and recommends appropriate alternatives
- Identifies and determines medical necessity of out of network (OON) requests for services
- Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing care
- Delivers timely written notification to patient or family members and communicates with members of the health care team
- Prepare cases that do not meet medical necessity or criteria for medical director review
- Communicate effectively with medical director regarding identified variances within the case against criteria utilized for medical review
- Regularly communicates with the UM Manager, Medical Director, physician advisor/reviewer and primary care physician for support, problem resolution and notification of decertification and appeals
- Using established screening tools, identify candidates and recommend enrollment into care management and disease management programs
- Identify quality of care issues and report for investigation per CHPW's policy
- Participates as part of the care management team; works collaboratively with all department staff
- Maintain professional growth and development through self-directed learning activities and/or involvement in professional, civic, and national/community organizations
- Reporting to work on time and for all scheduled shifts is essential to this position.
- Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.
Essential Functions (Utilization Management Clinician II)
- Perform all functions of a Utilization Management Clinician I
- Exceed minimum production average of 16 medical necessity reviews a day for a minimum of four consecutive months
- Exceed quality goal with over 90% accuracy on internal audits for a minimum of 4 consecutive months
- Proficient and able to support clinical reviews and member transition support in a minimum of two areas (inpatient physical health, outpatient physical health, appeals, and behavioral health)
- Able to maintain production and quality expectations while supporting multiple clinical areas
Essential Functions (Senior Utilization Management Clinician)
- Perform all functions of a Utilization Management Clinician II
- Exceed production average of 20 medical necessity reviews a day for a minimum of six consecutive months
- Exceed quality goal with over 95% accuracy on internal audits for a minimum of 6 consecutive months
- Train new and existing level I and II clinicians on Utilization Management workflow
- Performs quality audits to ensure accuracy of medical necessity reviews
- Updates employee training manuals and materials to align with current workflows and processes
- Supports process improvement initiatives within Health Services Division
QUALIFICATIONS:
Education:
- Bachelor’s degree in a relevant field or an equivalent combination of education and highly relevant experience required
License, Certifications, and other Specialized Training:
- Current, unrestricted license as an RN, LPN, LMHC, or LICSW
Prior Related Experience:
- At least two years clinical experience in either a physical health or behavioral health setting required
- Previous experience in Utilization Management and Managed Care preferred
Employment Eligibility:
- Candidate has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
Knowledge, Skills, and Abilities:
- Ability to effectively manage and maintain quality standards for high volume of authorization
- Ability to work independently
- Strong written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers
- Knowledge in criteria set, including MCG, InterQual, ASAM, and LOCUS preferred
- Ability to multi-task and deal with complex assignments on a frequent basis
- Perform all functions of the job with accuracy, attention to detail and within established timeframes.
- Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data
- Experience in care management workflow systems
- Effective verbal and written communication skills
- Flexibility and willingness to work in a matrix-management environment
- Demonstrated organizational, time management, and project management skills
- Ability to handle multiple priorities in a fast-paced environment
- Demonstrated proficiency and experience with Microsoft Office products
- Ability to present in a group setting
- Willingness to be part of a fast moving, and dynamic clinical development team
- Collaborate with others in a respectful manner
- Meet attendance and punctuality standards
- Demonstrate professional courtesy to others and ability to maintain confidentiality
To apply, please visit: https://www.chpw.org/contact-us/chpw-careers/
We're committed to our employees and their family, which is why we offer benefits that, makes a difference in their lives. Paid time off, tuition reimbursement, community service hours, and transportation perks are just a few of the offerings of our comprehensive and competitive benefits program.
Community Health Plan of Washington is an Equal Opportunity Employer with a diverse workforce!
Headquarters: 1111 3rd Avenue, Suite 400 Seattle, WA 98101