Utilization Management Clinician I

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🔥 2 minutes ago

☕ Washington – Remote

☕ Washington – Remote

💵 $35 - $55 / hour

⏰ Full Time

🟢 Junior

🟡 Mid-level

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Community Health Plan of Washington

WebsiteLinkedInAll Job Openings

501 - 1000 employees

Founded 1992

⚕️ Healthcare Insurance

👥 B2C

Healthcare Insurance • B2C

Community Health Plan of Washington is a nonprofit health plan founded in 1992 by Washington’s community health centers that provides Medicaid (Apple Health), Medicare Advantage, Dual-eligible, and Individual & Family insurance plans across Washington state. It offers care management, behavioral health, virtual care, member support and community services, and programs such as rewards, language assistance, and provider networks to serve members and community health needs.

📋 Description

• Perform utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools. • Identify, coordinate, and implement high quality, cost-effective alternatives when appropriate to the patient’s condition. • Support 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. • Ensure members have timely access to care and supports during transitions between levels of care. • Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies. • Conduct onsite visits to local facilities 1-3 times weekly to connect with members and support successful post-discharge transitions. • Collaborate with facilities to perform discharge planning. • Provide coordination support to members transitioning between care settings or returning home from a hospitalization. • Identify member needs and provide support to ensure necessary services are available during the transition period. • Collaborate with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes. • Identify, coordinate, and ensure 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.

🎯 Requirements

• 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. • Effective written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers. • Ability to multi-task and deal with complex assignments with competing priorities on a frequent basis. • Experience in care management workflow systems. • Demonstrated organizational, time management, and project management skills. • Demonstrated proficiency and experience with Microsoft Office products.

🏖️ Benefits

• 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