Clinical Program Manager III, Utilization Management and Operations Lead

1 week ago

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

Community Health Plan of Washington is seeking a highly skilled Clinical Program Manager III to lead our Utilization Management department. This role will be responsible for ensuring the efficiency, accuracy, and compliance of our UM functions, as well as providing training and support to clinical staff.

Key Responsibilities
  • Develop and deliver training programs for clinical staff on UM workflows and criteria, including MCG, ASAM, LOCUS, and internal criteria.
  • Conduct regular internal audits of clinical staff performance, evaluating adherence to UM standards, regulatory requirements, and organizational policies.
  • Provide comprehensive onboarding training for new clinicians joining the company.
  • Represent UM in interdepartmental meetings, serving as a subject matter expert and educator to ensure cross-functional understanding of UM workflows and processes.
  • Oversee departmental projects, including identification of initiatives, developing project plans and timelines, and overseeing project work until completion.
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, as well as advanced project management skills and experience.
  • Experience analyzing complex data sets to determine actionable insights and knowledge of standard utilization management processes, including utilization review, benefits, NCQA standards, and State and Federal requirements.
What We Offer
  • A competitive salary and 10% annual incentive target based on company, department, and individual performance goals.
  • A comprehensive benefits package, including medical, prescription, dental, and vision coverage, as well as flexible spending accounts, health savings accounts, and 401(k) retirement with a generous employer match.
  • A dynamic and supportive work environment, with opportunities for professional growth and development.

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