Senior Director, Utilization Management & Transitional Care

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 Cl