Clinical Program Manager III, Utilization Management

Job Description

Job Description

This position is available fully remote within 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.
• Become an anti-racist organization.
• Create an equitable work environment.

About the Role

The Utilization Management (UM) Clinical Program Manager plays a key role in ensuring the efficiency, accuracy, and compliance of the UM department functions.

Through robust training programs and ongoing education initiatives, the UM Clinical Program Manager assists clinical staff with the knowledge and skills needed to follow UM workflows and criteria effectively.

In addition to the training responsibilities, the role includes conducting regular internal audits to evaluate staff performance and ensure adherence to regulatory requirements and accreditation standards.

Additionally, the UM Clinical Program Manager provides valuable feedback and training for physician and pharmacy reviewers, fostering a culture of continuous learning and improvement within the department.

To be successful in this role, you :

• Have minimum four (4) years of experience in managed care utilization management operations and utilization of clinical criteria to make medical necessity decisions.
• Have a current, unrestricted license in the State of Washington as a Registered Nurse (RN), or a current compact RN licensure
• Possess knowledge of appeals and UM operations.
• Have advanced project management skills and experience.
• Experience analyzing complex data sets to determine actionable insights.
• Have knowledge of standard utilization management processes, including utilization review, benefits, NCQA standards, and State and Federal requirements.
• Possess experience with implementing, operating and / or regulating operational workflows.
• Knowledge of regulatory and certification requirements and their impact on the organization (for example, HEDIS, CAHPS, and NCQA).
• Have a bachelor’s degree in nursing (preferred).

Essential functions and Roles and Responsibilities :

• Develop and deliver training programs for clinical staff on UM workflows and criteria, including but not limited to MCG, ASAM (American Society of Addiction Medicine), LOCUS (Level of Care Utilization System), HTA (Health Technology Assessment) and internal criteria, ensuring comprehension and adherence to established standards.
• Provide comprehensive onboarding training for new clinicians joining the company.
• Oversee and conduct regular internal audits of clinical staff performance, evaluating adherence to UM standards, regulatory requirements, and organizational policies, and provides feedback on performance gaps to staff leadership.

Ensures accuracy in application of UM criteria by clinical staff.

• Ensure UM training meets all standards set forth by the National Committee for Quality Assurance (NCQA), Healthcare Authority (HCA), Centers for Medicare & Medicaid Services (CMS), and other relevant regulatory bodies.
• Proactively identify trends and patterns in audit findings, utilizing data analysis to inform targeted training initiatives aimed at improving accuracy and efficiency in UM workflows.
• Provide feedback and training for physician and pharmacy reviewers, collaborating with clinical leadership to address areas of improvement and enhance overall clinical performance within the UM department.
• Represent UM in interdepartmental meetings, serving as a subject matter expert and educator to ensure cross-functional understanding of UM workflows and processes throughout the organization.
• Oversee departmental projects including identification of initiatives, developing the project plan and timeline, and overseeing project work until completion of the project.
• 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 :

• Understanding of project management methods, concepts, programs, and other resources
• Advanced analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
• Knowledge in criteria set, including MCG, NCD, LCD, and others
• Effective verbal and written communication skills.
• Proficiency in MS Office.
• Advanced organizational, time management, and program management skills.
• Ability to perform all functions of the job with accuracy, attention to detail and within established timeframes.

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 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
• 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 :

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.