Program Manager II, 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

The Utilization Management Program Manager collaborates with the utilization management leadership team to develop and monitor utilization management programs across all lines of business, covering physical and behavioral health. This position provides expertise in analytics, reporting systems and project management to ensure that the utilization management program is compliant with regulatory requirements. Supporting the utilization management team involves measuring, tracking and analyzing productivity and outcome metrics, implementing process improvements and preparing policies and files for audits. The program manager is responsible for working with leaders and staff to standardize processes across all business lines.  

To be successful in this role, you:

• Possess a bachelor’s degree or an equivalent combination of education and highly relevant experience required.
• Have a minimum one (1) year of experience supporting utilization management programs required.
• Have a minimum one (1) year managed care experience required.
• Have project management experience required.
• Have knowledge of standard utilization management processes, including utilization review, benefits, NCQA standards, and State and Federal requirements.
• Have an understanding of reporting systems and program analytics.

Essential functions and Roles and Responsibilities:

• Collaborates with UM leadership to evaluate UM programs, identify opportunities for improvement, and implement new processes.
• Creates and implements utilization management workflows.
• Manages maintenance of policies, manuals, etc.
• Participates as a subject matter expert (SME) in internal cross-functional teams to ensure that utilization management programs meet regulatory requirements and elevates risk to leadership when programs are not in compliance.
• Drives program results as a SME for UM systems; Jiva, Provider One, Xcelys, Tableau, Pre-Manage, EPIC and other UM platforms.
• Collaborates with internal teams to revise and enhance utilization management applications.
• Manages regulatory audits including policy and file preparation.
• Prepares and analyzes utilization management productivity and outcome data.
• Measures, tracks and analyzes department goals.
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