Manager, Clinical Utilization Management – Transitions of Care

🕒 Abril 29

☕ Washington – Remoto

☕ Washington – Remote

💵 $101.740 - $163.800 / ano

⏰ Tempo Integral

🟡 Pleno

🟠 Sênior

👔 Gerente

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Community Health Plan of Washington

SiteLinkedInTodas as Vagas

501 - 1000 funcionários

Fundada em 1992

⚕️ Seguro de Saúde

👥 B2C

Healthcare Insurance • B2C

O Community Health Plan of Washington é um plano de saúde sem fins lucrativos, fundado em 1992 pelos centros de saúde comunitários de Washington, que oferece planos de seguro Medicaid (Apple Health), Medicare Advantage, Dual-eligible e Individual & Family em todo o estado de Washington. Oferece gerenciamento de cuidados, saúde comportamental, atendimento virtual, apoio aos membros e serviços comunitários, além de programas como recompensas, assistência linguística e redes de provedores para atender às necessidades de saúde dos membros e da comunidade.

Descrição

• Lead and manage the daily operation of the department, including staffing and scheduling, ensuring timely completion of UM reviews and Transition of Care activities (post-discharge calls and onsite facility visits) • Oversee TOC workflows, including 72-hour post-discharge outreach, member engagement, and coordination with inpatient and community providers to support safe transitions and reduce readmissions • Support and operationalize onsite facility engagement, partnering with hospitals and facilities to facilitate discharge planning, remove barriers, and improve follow-up care compliance • Ensure staff are trained and equipped to meet UM, TOC and engagement performance targets including clinical quality and financial outcomes • Establish and monitor individual and team performance goals, providing coaching and taking appropriate action to ensure that goals are achieved • Collaborate with the Director of Clinical Utilization Management to develop and implement initiatives, develop tactical plans, drive performance, and achieve targets • Ensure staff members maintain competency in UM reviews, TOC processes, and regulatory requirements • Promote on-going staff development through education and opportunities for professional development • Monitor departmental performance against key metrics (e.g timeliness, TOC compliance, readmission, quality of reviews) and implement process improvement • Lead and participate in departmental and interdepartmental workgroups to continually enhance the delivery of programs and services and proactively respond to changing client and market expectations • Ensure that all services are delivered consistently with applicable internal policies and procedures, regulatory agency requirements, and standards of practice for utilization management and transitions of care • Ensure processes and documentation meet NCQA and all regulatory requirements • Occasional travel for on-site visits may occur for staff onboarding, facility support, or leadership meetings in the Seattle office.

🎯 Requisitos

• Hold a current, unrestricted RN license in the State of Washington • Have a bachelor’s degree in nursing or an advanced clinical degree, or additional advanced clinical training, preferred • Have a minimum of three (3) years UM or CM experience required • Have a minimum of three (3) years leading teams required, experience working with remote workers desired OR a minimum of three (3) years in a supervisory or management role required • Have a minimum of three (3) years acute or ambulatory clinical experience in a medical/surgical or pediatric setting required • Possess a valid WA driver's license and have access to a reliable automobile • Have experience working in a managed care setting, including case and disease management, preferred • Have experience in review of behavioral health and/or substance abuse service preferred • Have experience with utilization management or care management workflow systems, as well as operational and utilization data, preferred.

🏖️ Benefícios

• 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 pay.