Manager, Behavioral Health Utilization Management

This position is available fully remote within Washington State

Who we are

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 apply an equity lens to all our work. 
• Reduce health disparities. 
• Become an anti-racist organization. 
• Create an equitable work environment. 

About the Role

Responsible for the facilitation of BH clinical medical necessity reviews on all member prior authorization and concurrent requests for outpatient services, admissions, and continued stays, as well as the transition of care calls for care coordination. The Manager, BH Utilization Management will develop and facilitate processes/workflows with the team, facilities, and other vendors to ensure completion of all requests in a timely manner.

To be successful in this role, you:

• Have an active Licensed Registered Nurse (RN) or a licensed Master’s Level Social Worker (LCSW, LMSW, LMSW-ACP, CSW, LPC, LMFT, LMHC) in the State of Washington without restrictions.
• Have a Bachelor’s degree in nursing (BSN), preferred.
• Have at least three (3) years of clinical experience working with the behavioral health populations preferably in an acute care, skilled or rehabilitation clinical setting.
• Have at least (2) years of leadership experience.
• Have previous experience in Utilization Management.
• Have prior knowledge and familiarity with CA/LOCUS, ASAM, CANS, and GAIN, preferred.

Essential functions and Roles and Responsibilities:

• Oversee BH UM daily operations including daily volumes, staffing, regulatory requirements, policy development, program oversight, and quality oversight.
• Review analyses of activities, costs, operation and forecast data to determine progress toward stated goals and objectives. Develop and generate reports to support efficient operations.
• Develop, implement and maintain compliance, policies and procedures regarding behavioral health utilization management functions.
• Ensure compliance with NCQA, federal and state regulations and contractual agreements.
• Establish appropriate staffing levels and work assignments, develop performance criteria for staff and serve as an expert resource on compliance, policies and operational procedures.
• Support the implementation of enhanced clinical tools to achieve standardization in process and data collection, identify areas where efficiencies can be achieved.
• Participate in quality audits, chart audits, and reviews of medical records as needed for either complex high cost cases or cases with quality of care concerns.
• Develop staff skills and competencies through training and experience. Be available to non-clinical staff as a resource for clinical questions.
• Performs management responsibilities to include but not limited to, involved in hiring and termination decisions, coaching and development, rewards and recognition, performance management and staff productivity.
• 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:

• Effective written, verbal, presentation and communication skills.
• Ability to lead, train and motivate teams, creating a positive and efficient work environment.
• Ability to set quality and productivity goals, monitor performance and proactively address opportunities for improvement.
• Ability to both participate in and lead program design, demonstrating a desire for continuous improvement.
• Ability to work independently under general instruction and with a team.
• Proficient analytic skills with the ability to interpret, evaluate and act on productivity, clinical and financial data.
• Comprehensive knowledge of Microsoft Office applications including Word, Excel, and Outlook.
• Excellent organizational, time management and project management skills.
• Knowledge in criteria set-Milliman and InterQual-preferred.
• Knowledge of adult and child behavioral health (mental health and substance use) systems of care.
• Knowledge of behavioral health evidence-based practices.

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 Exempt and is not eligible for overtime. Based on market data, this position grade is 69 (see full range below) and has a 10% annual incentive target based on company, department, and individual performance goals.

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&D, 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.
•  40 hours Community Service volunteer time
•  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
• 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:

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Work Environment:

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