Clinical Program Manager III

2 weeks ago

Seattle, Washington, United States Community Health Plan of Washington Full time
Job Title: Clinical Program Manager III - Utilization Management

Community Health Plan of Washington is seeking a highly skilled Clinical Program Manager III to join our Utilization Management team. As a key member of our team, you will play a critical role in ensuring the efficiency, accuracy, and compliance of our UM department functions.

Key Responsibilities:
  • Develop and deliver training programs for clinical staff on UM workflows and 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.
  • 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.
  • 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.
Requirements:
  • Minimum four (4) years of experience in managed care utilization management operations and utilization of clinical criteria to make medical necessity decisions.
  • 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.
  • Advanced project management skills and experience.
  • Experience analyzing complex data sets to determine actionable insights.
  • 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).
What We Offer:
  • Competitive salary and benefits package.
  • Opportunity to work with a dynamic and growing organization.
  • Collaborative and supportive work environment.
  • Professional development and growth opportunities.

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.

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