Behavioral Health Utilization Management Clinician I (RN)

Ultipro; Olympia, Tacoma (WA, WA); On-site; USD 72,000 - 95,000; Full time

Benefits offered by this job

Medical, Prescription, Dental, Vision

Telehealth app

401(k) retirement with match

PTO and holidays

Wellness programs

Job summary

Community Health Plan of Washington is seeking a Level I Utilization Management Clinician to perform utilization review and coordinate high-quality, cost-effective care. The role requires RN or LPN licensure and a bachelor’s degree, with 2+ years’ clinical experience in physical or behavioral health, and some prior utilization management exposure.

Travel to Pierce and Thurston Counties is required. You will support physician decision-making and collaborate with the health care team to ensure

Qualifications

• Bachelor's degree in a relevant field or equivalent education/experience.
• Current, unrestricted RN or LPN license.
• At least two years of clinical experience in physical or behavioral health.
• Experience in Utilization Management and Managed Care preferred.

Responsibilities

• Travel to local hospitals within Pierce and Thurston Counties.
• Review hospital notifications and prior authorization requests against guidelines.
• Coordinate discharge planning with facilities.
• Support members transitioning between care settings.
• Collaborate with providers and care teams to ensure timely care.
• Identify inappropriate or unnecessary services and suggest alternatives.
• Verify referrals and enrollment/benefits before authorizing care.
• Communicate findings to medical leadership and care teams.

Skills

Bachelor's degree in a relevant field

RN or LPN license

2+ years clinical experience

Utilization Management experience

Education

Bachelor's degree in a relevant field

Tools

MCG

InterQual

ASAM

LOCUS

Job description

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.

Our commitment is to:

• Strive to a pply an equity lens to all our work.
• Create an equitable work environment.

About the Role

The Level I Utilization Management Clinician 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. Understanding and effectively communications requirements and follows Community Health Plan of Washington (CHPW) policies and procedures.

To be successful in this role, you:

• Have a bachelor’s degree in a relevant field or an equivalent combination of education and highly relevant experience.
• Have a current, unrestricted license as an RN or LPN.
• Have at least two years clinical experience in either a physical health or behavioral health setting.
• Have previous experience in Utilization Management and Managed Care, preferred.

Essential functions and Roles and Responsibilities:

• This role does require travel to local hospitals within Pierce and Thurston Counties.
• 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. Identify 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.
• 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.

Knowledge, Skills, and Abilities:

• Ability to effectively manage and maintain quality standards for high volume of authorization.
• Ability to work independently.
• Effective 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 with competing priorities on a frequent basis.
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.
• Effective analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
• Experience in care management workflow systems.
• Flexibility and willingness to work in a matrix-management environment.
• Demonstrated organizational, time management, and project management skills.
• Demonstrated proficiency and experience with Microsoft Office products.
• Ability to present in a group setting.
• Willingness to be part of a collaborative and dynamic clinical development team.
• Collaborate with others in a respectful manner and ability to maintain confidentiality.

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check.

Criminal History:includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case‑by‑case basis considering the risk to the business, members, and/employees.

• 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.
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• 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.

Compensation and Benefits:

The position is FLSA Non-Exempt and is eligible for overtime and has a 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part‑time employees and their dependents:

• Medical, Prescription, Dental, and Vision
• Telehealth app
• Flexible Spending Accounts, Health Savings Accounts
• Basic Life AD&DD, Short and Long‑Term Disability
• Voluntary Life, Critical Care, and Long‑Term Care Insurance
• 401(k) Retirement and generous employer match
• Employee Assistance Program and Mental Fitness app
• Financial Coaching, Identity Theft Protection
• Time off including PTO accrual starting at 17 days per year.
• 10 standard holidays, 2 floating holidays
• Compassion time off, jury duty

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
• 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.

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.

Travel Required

Yes .

Behaviors

• Team Player: Works well as a member of a group
• Detail Oriented: Capable of carrying out a given task with all details necessary to get the task done well

Motivations

• Self-Starter: Inspired to perform without outside help
• Flexibility: Inspired to perform well when granted the ability to set your own schedule and goals

Education

• Preferred: Technical/other training or better in Nursing.

Licenses & Certifications

• RN
• LPN

Equal Opportunity Employer/Protected Veterans/Individuals with Disabilities

This employer is required to notify all applicants of their rights pursuant to federal employment laws.For further information, please review the Know Your Rights notice from the Department of Labor.