Manager, Clinical Utilization Management – Transitions of Care

🕒 il y a 1 mois

☕ Washington – Distant

☕ Washington – Remote

💵 $101 740 - $163 800 / an

⏰ Temps Plein

🟡 Intermédiaire

🟠 Senior

👔 Manager

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Community Health Plan of Washington

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501 - 1000 employés

Fondée en 1992

⚕️ Assurance santé

👥 B2C

Healthcare Insurance • B2C

Community Health Plan of Washington est un plan de santé à but non lucratif fondé en 1992 par les centres de santé communautaires de Washington. Il fournit des plans d'assurance pour Medicaid (Apple Health), Medicare Advantage, bi-éligibles, et individuels & familiaux à travers l'État de Washington. Il offre des services de gestion des soins, de santé comportementale, de soins virtuels, de soutien aux membres et de services communautaires, ainsi que des programmes tels que des récompenses, une assistance linguistique et des réseaux de prestataires pour répondre aux besoins des membres et de la santé communautaire.

Description

• 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.

🎯 Exigences

• 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.

🏖️ Avantages

• 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.