Senior Director, Utilization Management & Transitional Care

About the position

This position is a Hybrid role with the option for either full-time in office or a combination of remote/home and in-office work as required. The role will necessitate periodic meetings at the main office located in Seattle, Washington. Community Health Plan of Washington is an equal opportunity employer dedicated to fostering 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. The organization is committed to applying an equity lens to all its work, reducing health disparities, becoming an anti-racist organization, and creating an equitable work environment. The Senior Director of Utilization Management & Transitional Care is responsible for driving the vision and strategy for integrated medical and behavioral utilization management and transitional care programs. This includes overall planning, program and budget development, program implementation, and coordination to achieve quality and service-driven objectives. The role oversees all phases of development, organization, planning, and implementation of projects, initiatives, workflows, and processes to enhance quality-driven outcomes while ensuring compliance with all state, federal, and regulatory requirements. To be successful in this role, candidates must possess a bachelor's degree in nursing or a relevant field, with a master's degree preferred. A current, unrestricted license in the State of Washington as an RN or ARNP is required, along with a valid driver's license and an acceptable driving record. Candidates should have a minimum of ten years of utilization management or related managed care experience, including at least five years of progressively responsible leadership experience in utilization management, preferably within a managed care environment. Experience with state programs such as Medicaid and Medicare, as well as familiarity with regulatory and accreditation standards for utilization management, is also required. Additionally, candidates should have experience effectively leading and managing multiple teams within a large matrixed department.

Responsibilities
? Oversee the organization's comprehensive utilization management and transitional care strategy, including integrated teams performing utilization management functions for physical and behavioral health services.
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? Lead a systematic and comprehensive utilization management program that incorporates intake, clinical review, medical necessity, discharge planning, and post-discharge support for physical and behavioral health services, ensuring regulatory compliance with State (HCA), Federal (CMS), NCQA, and other oversight entities.
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? Lead the transitional care program that incorporates 72-hour post-discharge support and behavioral transitions, ensuring regulatory compliance with relevant standards.
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? Work effectively across departments to ensure seamless coordination and operational workflows between teams, including care management, claims, and appeals.
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? Share responsibility for operational oversight of Plan Medical Directors performing utilization review functions, ensuring schedules meet departmental needs and processes are established and monitored to support utilization management and transitional care programs.
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? Ensure effective oversight of UM operations and staff, working with department leadership to identify staffing and resource needs, engage in performance management, and foster a cohesive and productive work environment.
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? Collaborate with Healthcare Economics and other departments to analyze Plan population data for variances in utilization and recommend strategies for improvement.
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? Work with Business Process Operations leadership to ensure alignment of Utilization Management and Claims systems and operations, including oversight of the Code Look Up tool.
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? Collaborate with Plan Medical Directors, Pharmacy department, and other Clinical Services leadership to evaluate medical and behavioral utilization trends and develop remedial actions and new program policies.
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? Implement relevant components of new product lines and actively support quality improvement principles to enhance utilization processes.
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? Oversee key performance indicators and ensure timely reporting to internal committees and leadership.
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? Monitor and develop annual department budgets and participate as an active member on assigned committees.

Requirements
? Bachelor's degree in nursing or other relevant field (required)
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? Master's degree in nursing or other relevant field (preferred)
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? Current, unrestricted license in the State of Washington as an RN or ARNP (required)
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? Current driver's license and an acceptable driving record (required)
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? Minimum of ten (10) years of utilization management or related managed care experience, with at least five (5) years of progressively responsible leadership experience in utilization management (required)
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? Experience with state programs, such as Medicaid and Medicare (required)
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? Experience with regulatory and accreditation standards for utilization management (required)
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? Minimum of five (5) years of experience effectively leading and managing multiple teams/large matrixed departments
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? Knowledge of managed care operations and the linkages between components such as quality improvement, disease management, population health management, care management, and claims operations.

Nice-to-haves
? Familiarity with process improvement and systems thinking, including process mapping and data collection methods.
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? Excellent customer service skills with internal and external customers.
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? Highly effective communication skills, both orally and in writing, with the ability to translate strategy into action.
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? Advanced analytical and problem-solving skills; critical thinking skills.

Benefits
? Medical, Prescription, Dental, and Vision insurance
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? Telehealth app
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? Flexible Spending Accounts, Health Savings Accounts
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? Basic Life AD&D, Short and Long-Term Disability insurance
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? Voluntary Life, Critical Care, and Long-Term Care Insurance
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? 401(k) Retirement plan with generous employer match
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? Employee Assistance Program and Mental Fitness app
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? Financial Coaching and Identity Theft Protection
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? PTO accrual starting at 17 days per year
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? 40 hours Community Service volunteer time
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? 10 standard holidays and 2 floating holidays
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? Compassion time off and jury duty leave

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