Location: Seattle,WA, USA
Working Each Day to Make a DifferenceAt Community Health Plan of Washington, we're driven by our belief that everyone deserves access to quality health care.More than 25 years ago, we made a commitment to improve the health of our communities by making quality health care accessible to all Washington state residents.We continue that pledge today by providing affordable comprehensive coverage to more than 315,000 individuals and families throughout the state.We are a local not-for-profit health plan in Washington State.We are committed to keeping Washington families healthy.We connect our communities to the health resources they need.We provide access to high-quality care for our members.We connect and empower our members through technology.The Community Health Centers we partner with strive to support members with a comprehensive mix of medical resources in one convenient location.Our partnerships with Community Health Centers and our extended provider network help us improve the health care delivery system.To learn more about how you can make a difference working at Community Health Plan of Washington, visit www.chpw.org {rel= nofollow }.*Clinical Program Manager III, Utilization Management * This position is available fully remote within Washington State* *[POSITION PURPOSE:]{.underline}The Utilization Management (UM) Clinical Program Manager plays a key role in ensuring the efficiency, accuracy, and compliance of the UM department functions. Through robust training programs and ongoing education initiatives, the UM Clinical Program Manager assists clinical staff with the knowledge and skills needed to follow UM workflows and criteria effectively. In addition to the training responsibilities, the role includes conducting regular internal audits to evaluate staff performance and ensure adherence to regulatory requirements and accreditation standards. Additionally, the UM Clinical Program Manager provides valuable feedback and training for physician and pharmacy reviewers, fostering a culture of continuous learning and improvement within the department.[PRINCIPAL DUTIES:]{.underline}Develop and deliver training programs for clinical staff on UM workflows and criteria, including but not limited to MCG, ASAM (American Society of Addiction Medicine), LOCUS (Level of Care Utilization System), HTA (Health Technology Assessment) and internal criteria, ensuring comprehension and adherence to established standards.Provide comprehensive onboarding training for new clinicians joining the company.Oversee and conduct regular internal audits of clinical staff performance, evaluating adherence to UM standards, regulatory requirements, and organizational policies, and provides feedback on performance gaps to staff leadership. Ensures accuracy in application of UM criteria by clinical staff.Ensure UM training meets all standards set forth by the National Committee for Quality Assurance (NCQA), Healthcare Authority (HCA), Centers for Medicare & Medicaid Services (CMS), and other relevant regulatory bodies.Proactively identify trends and patterns in audit findings, utilizing data analysis to inform targeted training initiatives aimed at improving accuracy and efficiency in UM workflows.Provide feedback and training for physician and pharmacy reviewers, collaborating with clinical leadership to address areas of improvement and enhance overall clinical performance within the UM department.Represent UM in interdepartmental meetings, serving as a subject matter expert and educator to ensure cross-functional understanding of UM workflows and processes throughout the organization.Oversee