Senior Director, Utilization Management & Transitional Care

Job Description

Job Description

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.

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.
• Become an anti-racist organization.
• Create an equitable work environment.

About the Role

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.

To be successful in this role, you :

• Possess a bachelor’s degree in nursing or other relevant field (required)
• Have a master’s degree in nursing or other 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)

Essential functions and Roles and Responsibilities :

• 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.

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.

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 Exempt and is not eligible for overtime and has a 15% 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
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination / pronation, wrist flexion
• 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 :

Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

Work Environment :

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.