Utilization Management Clinician

3 weeks ago


Houston, Texas, United States Community Health Plan of Washington Full time
Job Summary

We are seeking a highly skilled Utilization Management Clinician to join our team at Community Health Plan of Washington. As a key member of our healthcare team, you will play a critical role in ensuring our members receive high-quality, cost-effective care.

Key Responsibilities
  • Conduct thorough reviews of hospital notifications and prior authorization requests to ensure medical necessity and adherence to health plan policies.
  • Collaborate with healthcare facilities to facilitate discharge planning and coordinate care transitions.
  • Provide support to members transitioning between care settings, ensuring timely access to necessary services and resources.
  • Work closely with providers, office staff, and care coordination teams to ensure seamless coordination of care and timely completion of referrals.
  • Identify and address potential unnecessary services or delivery settings, recommending alternative solutions to promote high-quality care.
  • Assess medical necessity of out-of-network requests and ensure referrals are complete and eligibility benefits are verified prior to authorizing care.
  • Communicate effectively with members, healthcare teams, and stakeholders to ensure timely written notification and coordination of care.
  • Prepare cases for medical director review and communicate variances in medical necessity criteria.
  • Participate in care management teams, working collaboratively with department staff to achieve optimal patient outcomes.
Requirements
  • Bachelor's degree in a relevant field or equivalent combination of education and experience.
  • Current, unrestricted license as an RN or LPN.
  • At least two years of clinical experience in physical health or behavioral health settings.
  • Previous experience in utilization management and managed care is preferred.
What We Offer
  • Competitive base pay and 10% annual incentive target.
  • Comprehensive benefits package, including medical, dental, vision, and 401(k) retirement plan.
  • Flexible work arrangements and opportunities for professional growth and development.
  • Collaborative and dynamic work environment with a team of dedicated healthcare professionals.


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