Remote Nurse Informaticist: Interoperability & Policy Lead

State of Washington; Nebraska; Remoto; USD 110.000 - 165.000; Tempo integral

Benefícios oferecidos por esta vaga

Remote work

Flexible scheduling

Medical/dental/vision insurance

Paid vacation and holidays

Retirement options

Resumo da vaga

Washington State Health Care Authority seeks a Clinical Nurse Specialist (Nurse Informaticist) to lead the implementation of state and federal prior authorization interoperability requirements within Apple Health (Medicaid). You will design workflows, apply clinical judgment to policy, and act as SME on API, provider directories and CMS/WAC rulemaking.

You will collaborate with Medicaid divisions, payers, and EHR vendors to automate data exchange, review utilization, and guide policy updates.

Qualificações

• Active unrestricted Washington State RN license or Multi-State License.
• Interoperability & HIT API & Data Standards Expertise: Deep knowledge of APIs HL7 and FHIR for patient access/provider directories/Prior Authorization.
• EHR Integration: Ability to align complex provider EHRs and practice management systems with payer databases.
• Workflow Automation: Design and implement standard nonproprietary open workflows that automate data collection.
• Regulatory Compliance & Policy Leadership: Interpret CMS rulemaking and Washington Administrative Codes (WACs).
• Policy Formulation: Advise leadership on financial and clinical utilization impacts of new health care regulations.
• Advanced Utilization Review: Evaluate complex medical records for medical necessity.
• Administrative Hearing Defense: Prepare statements and testimony for appeals and utilization reviews.
• System Leadership & Change Management: Bridge clinical and technical teams across agencies and providers.
• Contract & Resource Management: Negotiate and monitor health care and technology vendor contracts.
• Clinical Education & Mentorship: Serve as clinical resource for Medicaid programs.

Responsabilidades

• Lead oversight and implementation of information exchange for prior authorization and API in Medicaid.
• Coordinate with divisions, payers, EHRs and practice management systems to identify documentation requirements and support automated data exchange.
• Guide configuration of Medicaid policies into payment systems and act as SME on POA, provider directory, and interoperability initiatives.
• Represent Washington State Medicaid in CMS rulemaking and WEDI forums.
• Conduct utilization reviews and make determinations using evidence-based policy and WAC requirements.
• Review reconsideration requests and prepare agency positions for hearings.
• Apply CPT and HCPCS updates to clinical policies, provider guides, and notices.
• Analyze POA and API metrics for reporting and advise on policy impacts.
• Negotiate and monitor contracts; liaise with DSHS, Dept. of Health, Dept. of Corrections and provider groups.

Conhecimentos

API & data standards

EHR integration

Workflow automation

Regulatory interpretation

Policy formulation

Utilization review

Administrative hearings

Cross-functional liaison

Contract & vendor management

Clinical education & mentorship

Formação

RN license (Washington)

MSN/MBA/MHA preferred

Ferramentas

HL7

FHIR

Descrição da vaga

Washington State Health Care Authority seeks a Clinical Nurse Specialist (Nurse Informaticist) to lead the implementation of state and federal prior authorization interoperability requirements within Apple Health (Medicaid). You will design workflows, apply clinical judgment to policy, and act as SME on API, provider directories and CMS/WAC rulemaking.

You will collaborate with Medicaid divisions, payers, and EHR vendors to automate data exchange, review utilization, and guide policy updates.