Care Coordinator Clinician Role

1 month ago

Seattle, Washington, United States CHPW Full time
Job Overview

This role involves working as a Care Coordinator Clinician at Community Health Plan of Washington. The position is available fully remotely from various locations, including Washington, Oregon, Idaho, Texas, and Florida.

About Us

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 protected characteristic or other unlawful consideration.

We 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 Clinician performs utilization review for medical or behavioral health requests using established criteria, technologies, and tools. They identify, coordinate, and implement high-quality, cost-effective alternatives when necessary. This professional supports physician decision-making, working collaboratively with healthcare teams, patients, families, coworkers, and internal and external customers to achieve optimal patient outcomes. Ensuring timely access to care and supporting transitions between care levels is essential. They understand and effectively communicate requirements and follow Community Health Plan of Washington (CHPW) policies and procedures.

To be successful in this role, you should have:
  • A bachelor's degree in a relevant field or an equivalent combination of education and highly relevant experience.
  • A current, unrestricted license as an RN or LPN.
  • At least two years of clinical experience in either physical health or behavioral health settings.
  • Previous experience in Utilization Management and Managed Care is preferred.
Key Responsibilities

Conduct reviews of hospital notifications 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. Identify member needs and ensure necessary services are available during transition periods. Collaborate with providers, office staff, and Care Coordination teams to assure timely coordination of care according to contractual and regulatory timeframes. Identify, coordinate, and ensure high-quality care by focusing on supporting access to care and services across the continuum of care according to patients' medical needs. Identify potentially unnecessary services and/or delivery settings and recommend appropriate alternatives. Determine medical necessity of out-of-network (OON) requests for services. Ensure referrals are complete and enrollment/eligibility benefits verified before authorizing care. Deliver timely written notifications to patients or family members and communicate with healthcare team members. Prepare cases that do not meet medical necessity or criteria for medical director review. Communicate effectively with the Medical Director regarding identified variances within cases against utilized criteria. Regularly communicate 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. Participate as part of the care management team; work collaboratively with all department staff.

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