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.
Senior Director, Utilization Management & Transitional Care
This position is a Hybrid position with the option for either full-time in office or hybrid between remote/home and in office as required. It will require periodic meetings in the main office in Seattle. Any candidate located within Washington State is welcome to apply.
POSITION PURPOSE:
This role drives vision and strategy for the integrated medical and behavioral utilization management/ transitional care programs, including overall planning, program and budget development, program implementation, and coordination to achieve quality and service-driven objectives. Oversees all phases of development, organization, planning, and implementation of projects/initiatives/workflows/processes to enhance quality-driven outcomes and ensure programs meet all state, federal and regulatory requirements.
PRINCIPAL DUTIES:
- Oversee the organization’s comprehensive utilization management and transitional care strategy. Includes integrated teams performing utilization management functions for physical and behavioral health services.
- Leads systematic and comprehensive utilization management program that incorporates intake, clinical review, medical necessity, discharge planning, and post discharge support for physical and behavioral health services, including written policies and procedures that ensure regulatory compliance with State (HCA), Federal (CMS), NCQA and other oversight entities.
- Leads transitional care program that incorporates 72-hour post-discharge support and behavioral transitions, including policies and procedures that ensure regulatory compliance with State (HCA), Federal (CMS), NCQA and other oversight entities.
- Works effectively across departments to ensure seamless coordination and operational workflows between teams (i.e. care management, claims, appeals)
- Shares responsibility for operational oversight of Plan Medical Directors performing utilization review functions, including ensuring schedules meet the needs of the department and processes are established and monitored to support the utilization management and transitional care programs.
- Responsible for ensuring effective oversight of UM operations and staff, including working with department leadership to identify staffing and resource needs, ensure effective hiring, engage in appropriate performance management and staff development, with the goal of developing a cohesive, empowered, and productive work environment.
- Works collaboratively with Healthcare Economics and other departments to establish mechanisms and processes to regularly analyze the Plan population data for variances in utilization to identify and recommend the highest impact opportunities and department-level strategies for interventions to improve cost, utilization, and quality outcomes.
- Works collaboratively with Business Process Operations (BPO) leadership to ensure Utilization Management and Claims systems and operations are in alignment. This includes oversight of the review and updates of the Code Look Up tool in collaboration with BPO.
- Works collaboratively with the Plan Medical Directors, Pharmacy department, and other Clinical Services leadership to evaluate medical and behavioral utilization trends, outliers, and high-risk indicators, developing remedial actions, and new program policies or strategies to ensure that adverse trends are appropriately managed.
- Successfully implements relevant components of new product lines. Actively uses and supports quality improvement principles and methods to improve utilization processes. Participates on quality improvement project teams as a member, leader, and/or sponsor.
- Oversees key performance indicators and ensures timely reporting to appropriate internal committees and leadership.
- Oversees development and monitoring of annual department budgets.
- Participates as an active member on committees as assigned, including co-chairing the Plan Utilization Management Committee.
- 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:
- Possess a bachelor’s degree in nursing or another relevant field (required)
- Have a master’s degree in nursing or another relevant field (preferred)
- Have a current, unrestricted license in the State of Washington as an RN or ARNP (required)
- Have a current driver’s license and an acceptable driving record (required)
- Have a minimum of ten (10) years utilization management or related managed care experience, with a minimum of five (5) years progressively responsible leadership experience in the areas of utilization management, preferably in a managed care environment (required)
- Have experience with state programs, such as Medicaid and Medicare, (required)
- Have experience with regulatory and accreditation (i.e., State, Federal, NCQA accreditation) standards for utilization management (required)
- Have a minimum of five (5) years of experience effectively leading and managing multiple teams/large matrixed department.
- Knowledge of the various components of managed care operations and the linkages between them (quality improvement, disease management, population health management, care management, and claims operations)
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.
- Complete and successfully pass a criminal background check.
Knowledge, Skills, and Abilities:
- Familiarity with process improvement and systems thinking, including process mapping, data collection methods and analysis.
- Excellent customer service skills with internal and external customers to the department
- Highly effective communicator orally and in writing, with the ability to translate strategy into action.
- Advanced analytical and problem-solving skills; critical thinking skills.
- Articulates organizational vision and implements strategic initiatives, with the ability to identify systemic issues to promote real change.
- Promotes and role-models a culture of collaboration and accountability, engaging effectively with staff at all levels of the organization and across departments.
- Perform all functions of the job with accuracy, attention to detail and within established timeframes.
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