Utilization Management Clinician I (RN)

This position is available fully remote in 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. 
• Create an equitable work environment. 

About the Role

The Level I Utilization Management Clinician performs utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient’s condition. Supports 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. Ensures members have timely access to care and supports during transitions between levels of care. Understands and effectively communicates requirements and follows Community Health Plan of Washington (CHPW) policies and procedures.

To be successful in this role, you:

• 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.

Essential functions and Roles and Responsibilities:

• Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies.
• Collaborate with facilities to perform discharge planning.
• Provide coordination support to members transitioning between care settings or returning home from a hospitalization. Identifies member needs and provides support to ensure necessary services are available during the transition period.
• Collaborates with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes.
• Identifies, coordinates, and ensures 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.
• Identify potentially unnecessary services and/or delivery settings and recommends appropriate alternatives.
• Identifies and determines medical necessity of out of network (OON) requests for services.
• Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing care.
• Delivers timely written notification to patient or family members and communicates with members of the health care team.
• Prepare cases that do not meet medical necessity or criteria for medical director review.
• Communicate effectively with medical director regarding identified variances within the case against criteria utilized for medical review.
• Regularly communicates with the UM Manager, Medical Director, physician advisor/reviewer and primary care physician for support, problem resolution and notification of decertification and appeals.
• Using established screening tools, identify candidates and recommend enrollment into care management and disease management programs.
• Identify quality of care issues and report for investigation per CHPW's policy.
• Participates as part of the care management team; works collaboratively with all department staff.
• Reporting to work on time and for all scheduled shifts is essential to this position.
• 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:

• Ability to effectively manage and maintain quality standards for high volume of authorization.
• Ability to work independently.
• Effective written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers.
• Knowledge in criteria set, including MCG, InterQual, ASAM, and LOCUS preferred.
• Ability to multi-task and deal with complex assignments with competing priorities on a frequent