Nurse Informaticist: Remote Interoperability & PA Expert

Washington State Health Care Authority; Olympia (WA); Remote; USD 110,000 - 150,000; Full time

Job summary

Washington State Health Care Authority seeks a Clinical Nurse Specialist with nurse informatics expertise to lead the implementation of prior authorization interoperability requirements and related policy and workflow improvements. The role focuses on integrating clinical judgment with informatics to streamline decisions while ensuring medically necessary care for Apple Health clients.

The incumbent will coordinate with divisions, payers, and EHR systems, serve as a subject matter expert on

Responsibilities

• Lead oversight and implementation of the information exchange components of state and federal legislation regarding prior authorization and API for HCA and Medicaid.
• Coordinate with HCA divisions, payers, and EHR and practice management systems to identify documentation requirements and support nonproprietary open workflows.
• Guide the configuration of Medicaid policies into payment systems and serve as subject matter expert on prior authorization, provider directory, patient access, and interoperability initiatives.
• Represent the Washington State Medicaid perspective in CMS rulemaking and in forums such as WEDI.
• Conduct utilization reviews and make prior authorization and claim payment determinations using evidence-based clinical policy and WAC 182-501-0165.
• Review reconsideration requests, prepare the agency's position for administrative hearings, and provide declarations/testimony as needed.
• Apply CPT and HCPCS code updates to clinical policies, provider guides, and notices.
• Analyze prior authorization and API metrics for state and federal reporting and advise leadership on policy and regulations, including cost and utilization impacts.
• Negotiate and monitor contracts, support bill analysis and decision packages, and liaise with DSHS, the Department of Health, the Department of Corrections, and provider groups.

Job description

Washington State Health Care Authority seeks a Clinical Nurse Specialist with nurse informatics expertise to lead the implementation of prior authorization interoperability requirements and related policy and workflow improvements. The role focuses on integrating clinical judgment with informatics to streamline decisions while ensuring medically necessary care for Apple Health clients.

The incumbent will coordinate with divisions, payers, and EHR systems, serve as a subject matter expert on