The clinician conducts utilization review for medical or behavioral health requests against established guidelines and policies, identifying and coordinating high-quality, cost-effective alternatives for patient care. They ensure members have timely access to care, support transitions between care settings, and collaborate with the healthcare team to achieve optimal patient outcomes.
Requirements summary
Candidates must possess a bachelor's degree or equivalent experience, along with a current, unrestricted RN or LPN license, and at least two years of clinical experience in physical or behavioral health. Previous experience in Utilization Management and Managed Care is preferred.
This position is available fully remote in Washington state.
Who We Are
Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.
Our commitment is to
Strive to apply an equity lens to all our work.
Reduce health disparities.
Create an equitable work environment.
About the Role
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.
To be successful in this role, you
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.
Essential functions and Roles and Responsibilities
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.
Benefits
Employee Assistance Program
Medical
Dental
Vision
Paid Time Off
Identity Theft Protection
Flexible Spending Accounts
Health Savings Accounts
Financial Coaching
Prescription
Critical Care
Long-Term Care Insurance
401(k) Retirement
Voluntary Life
Short And Long-Term Disability
Basic Life Ad&D
Telehealth app
Community Service Volunteer Time
Mental Fitness App
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.
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.
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.
Note
If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.
As part of our hiring process, the following criteria must be met
• Complete and successfully pass a criminal background check.
Criminal History
includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.
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.
Vaccination requirement (CHPW offers a process for medical or religious exemptions)
Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.
Compensation and Benefits
The position is FLSA Non-Exempt and is eligible for overtime and has a 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.
CHPW offers the following benefits for Full and Part-time employees and their dependents:
Medical, Prescription, Dental, and Vision
Telehealth app
Flexible Spending Accounts, Health Savings Accounts
Basic Life AD&D, Short and Long-Term Disability
Voluntary Life, Critical Care, and Long-Term Care Insurance
401(k) Retirement and generous employer match
Employee Assistance Program and Mental Fitness app
Financial Coaching, Identity Theft Protection
Time off including PTO accrual starting at 17 days per year.
40 hours Community Service volunteer time
10 standard holidays, 2 floating holidays
Compassion time off, jury duty
Sensory/Physical/Mental Requirements
Sensory*
• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.
Physical*
Extended periods of sitting, computer use, talking and possibly standing
Frequent torso/back static position; occasional stooping, bending, and twisting.
Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.
Mental
• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.
Work Environment
Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.
