Utilization Management Clinician I (RN)

This position is available remotely in Washington, Oregon, Idaho, Texas and Florida. 

Job Summary

Performs utilization review for medical or behavioral health requests using utilization review criteria, technologies and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient’s condition. Supports physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes. Ensures members have timely access to care and supports during transitions between levels of care. Understands and effectively communicates requirements, and follows Community Health Plan of Washington (CHPW) policies and procedures.

Essential Functions (Utilization Management Clinician I)

• Conduct review of hospital notification 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. Identifies member needs and provides support to ensure necessary services are available during the transition period.
• Collaborates with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes
• Identifies, coordinates, and ensures high quality care and appropriate care by focusing on supporting access to care and services across the continuum of care in accordance with the patient’s medical needs
• Identify potentially unnecessary services and/or delivery settings and recommends appropriate alternatives
• Identifies and determines medical necessity of out of network (OON) requests for services
• Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing care
• Delivers timely written notification to patient or family members and communicates with members of the health care team
• Prepare cases that do not meet medical necessity or criteria for medical director review
• Communicate effectively with medical director regarding identified variances within the case against criteria utilized for medical review
• Regularly communicates 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
• Participates as part of the care management team; works collaboratively with all department staff
• Maintain professional growth and development through self-directed learning activities and/or involvement in professional, civic, and national/community organizations
• Reporting to work on time and for all scheduled shifts is essential to this position.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Essential Functions (Utilization Management Clinician II)

• Perform all functions of a Utilization Management Clinician I
• Exceed minimum production average of 16 medical necessity reviews a day for a minimum of four consecutive months
• Exceed quality goal with over 90% accuracy on internal audits for a minimum of 4 consecutive months
• Proficient and able to support clinical reviews and member transition support in a minimum of two areas (inpatient physical health, outpatient physical health, appeals, and behavioral health)
• Able to maintain production and quality expectations while supporting multiple clinical areas

Essential Functions (Senior Utilization Management Clinician)

• Perform all functions of a Utilization Management Clinician II
• Exceed production average of 20 medical necessity reviews a day for a minimum of six consecutive months
• Exceed quality goal with over 95% accuracy on internal audits for a minimum of 6 consecutive months
• Train new and existing level I and II clinicians on Utilization Management workflow
• Performs quality audits to ensure accuracy of medical necessity reviews
• Updates employee training manuals and materials to align with current workflows and processes
• Supports process improvement initiatives within Health Services Division

Qualifications

Education

• Bachelor’s degree in a relevant field or an equivalent combination of education and highly relevant experience required

 License, Certifications, and other Specialized Training

• Current, unrestricted license as an RN or LPN.

Experience

• At least two years clinical experience in either a physical health or behavioral health setting required
• Previous experience in Utilization Management and Managed Care preferred

Employment Eligibility

• 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

Knowledge, Skills, and Abilities

• Ability to effectively manage and maintain quality standards for high volume of authorization
• Ability to work independently
• Strong written and verbal communication skills; able to communicate with and collaborate effectively with physicians and allied health care providers
• Knowledge in criteria set, including MCG, InterQual, ASAM, and LOCUS preferred
  • Ability to multi-task and deal with complex assignments on a frequent basis
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.
• Strong analytical skills and the ability to interpret, evaluate and formulate action plans based upon data
• Experience in care management workflow systems
• Effective verbal and written communication skills
• Flexibility and willingness to work in a matrix-management environment
• Demonstrated organizational, time management, and project management skills
• Ability to handle multiple priorities in a fast-paced environment
• Demonstrated proficiency and experience with Microsoft Office products
• Ability to present in a group setting
• Willingness to be part of a fast moving, and dynamic clinical development team
  • Collaborate with others in a respectful manner
  • Meet attendance and punctuality standards
• Demonstrate professional courtesy to others and ability to maintain confidentiality

SENSORY/PHYSICAL/MENTAL REQUIREMENTS

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

 Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion
• Frequent torso/back static position; occasional stooping, bending and twisting
• Some kneeling, pushing, pulling, lifting and carrying (not over 25 pounds), twisting and reaching

Mental:

• Ability to learn and prioritize multiple tasks at a given time and have the capability of handling demanding situations. Analytical/problem solving/critical thinking ability.

WORK ENVIRONMENT

Office environment with frequent environmental exposure to low-grade radiation from computer monitors; fast paced with frequent interruptions.

PROTECTED HEALTH INFORMATION (PHI) ACCESS

All information (written, verbal, electronic, etc.) that an employee encounters while working at CHPW is considered confidential.  CHPW employees may encounter protected health information in the regular course of their work at and for CHPW.  This position may be exposed to and required to deal with highly confidential and sensitive material and must adhere to CHPW policies, guidelines, and all applicable laws and regulations at all times. 

*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.

 This job description is intended to describe the general content and the requirements for satisfactory performance in this position. It is not to be construed as an exhaustive statement of the duties, responsibilities or requirements of this position.

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.