Senior Director Utilization Management

1 day ago

Washington DC United States ASSOCIATION FOR COMMUNITY AFFILIATED PLANS Full time

At Community Health Plan of Washington (CHPW), you’ll find a culture of professionals dedicated to applying an equity lens to all work, reducing health disparities, and becoming an anti-racist organization. The Senior Director, Utilization Management (UM) and Transitional Care (TC) is a pivotal role that will drive vision and strategy for CHPW’s integrated medical and behavioral utilization management and transitional care programs. CHPW is committed to cultivating a diverse and inclusive workforce. Find your career home with Community Health Plan of Washington

About the Role

Reporting to the VP of Health Services, the Senior Director of UM & TC will oversee the comprehensive UM and TC strategy, ensuring CHPW’s programs meet all state, federal, and regulatory requirements. The Senior Director will work across departments to ensure seamless coordination and operational workflows, leading a team of approximately 70 members, including two direct reports who manage non-clinical and clinical work.

Key Responsibilities Include:

  • Leading the systematic and comprehensive UM program incorporating intake, clinical review, medical necessity, discharge planning, and post-discharge support
  • Ensuring compliance with State (HCA), Federal (CMS), and NCQA regulatory standards
  • Developing and implementing strategic initiatives to enhance quality-driven outcomes and meet regulatory requirements
  • Building strong relationships with key stakeholders and collaborating effectively across departments
  • Overseeing key performance indicators and ensuring timely reporting to internal committees, external regulators, and leadership

What We’re Looking For

  • A Bachelor’s degree in nursing or a relevant field (Master’s degree preferred)
  • A current unrestricted RN or ARNP license in the State of Washington
  • At least ten years of progressive UM or related managed care experience, with five years in a leadership role
  • Experience with Medicaid, Medicare, and DSNP programs, including knowledge of CMS and NCQA standards
  • Strong analytical and problem-solving skills, with the ability to drive change through data-driven decision-making
  • An inclusive leadership style with a transformational spirit, open to innovative ideas and out-of-the-box thinking
  • Ability to build and maintain effective working relationships across departments and with external stakeholders

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

As part of our hiring process, the following criteria must be met:

  • Complete and successfully pass a criminal background check
  • 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
  • 10 standard holidays, 2 floating holidays
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