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. Utilization Management Clinician I - RN or LPN This position is available fully remote from Washington, Oregon, Idaho, Texas, and Florida.
POSITION PURPOSE: The Level I Utilization Management Clinician 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.
- 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.
QUALIFICATIONS:
Education & Prior Related Experience: - Have a bachelor’s degree in a relevant field or an equivalent combination of education and highly relevant experience.
- Have a current, unrestricted license as an RN or LPN.
- Have at least two years clinical experience in either a physical health or behavioral health setting.
- Have 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.
- Effective 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 with competing priorities on a frequent basis.
- Perform all functions of the job with accuracy, attention to detail and within established timeframes.
- Effective analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
- Experience in care management workflow systems.
- Flexibility and willingness to work in a matrix-management environment.
- Demonstrated organizational, time management, and project management skills.
- Demonstrated proficiency and experience with Microsoft Office products.
- Ability to present in a group setting.
- Willingness to be part of a collaborative and dynamic clinical development team.
- Collaborate with others in a respectful manner 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 |