Clinical Program Manager III, Utilization Management

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 o