Utilization Management Clinician I - RN or LPN - 100% Remote

Working Each Day to Make a Difference At 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, visitwww.chpw.org{rel="nofollow"}. •

• Utilization Management Clinician I - RN or LPN

100% Remote •

• [POSITION PURPOSE:]{.underline}

The Level I Utilization Management Clinician performs utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools. Identifies, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient's condition. Supports physician decision-making, working collaboratively with all members of the health care team, the patient, the patient's family, co-workers, and internal and external customers to achieve optimal patient outcomes. Ensures members have timely access to care and supports during transitions between levels of care. Understands and effectively communicates requirements and follows Community Health Plan of Washington (CHPW) policies and procedures. [PRINCIPAL DUTIES:]{.underline} Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies. Collaborate with facilities to perform discharge planning. Provide coordination support to members transitioning between care settings or returning home from a hospitalization. Identifies member needs and provides support to ensure necessary services are available during the transition period. Collaborates with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes. Identifies, coordinates, and ensures high quality care and appropriate care by focusing on supporting access to care and services across the continuum of care in accordance with the patient's medical needs. Identify potentially unnecessary services and/or delivery settings and recommends appropriate alternatives. Identifies and determines medical necessity of out of network (OON) requests for services. Assures referrals are complete and enrollment/eligibility benefits verified, prior to authorizing care. Delivers timely written notification to patient or family members and communicates with members of the health care team. Prepare cases that do not meet medical necessity or criteria for medical director review. Communicate effectively with medical director regarding identified variances within the case against criteria utilized for medical review. Regularly communicates with t Apply Job!