Senior Director Utilization Management & Transitional Care

At Community Health Plan of Washington (CHPW), you’ll find a culture of professionals dedicated to applying an equity lens to all work, reducing health disparities, and becoming an anti-racist organization. The Senior Director, Utilization Management (UM) and Transitional Care (TC) is a pivotal role that will drive vision and strategy for CHPW’s integrated medical and behavioral utilization management and transitional care programs. CHPW is committed to cultivating a diverse and inclusive workforce. Find your career home with Community Health Plan of Washington!About the RoleReporting to the VP of Health Services, the Senior Director of UM & TC will oversee the comprehensive UM and TC strategy, ensuring CHPW’s programs meet all state, federal, and regulatory requirements. The Senior Director will work across departments to ensure seamless coordination and operational workflows, leading a team of approximately 70 members, including two direct reports who manage non-clinical and clinical work.Key Responsibilities Include:Leading the systematic and comprehensive UM program incorporating intake, clinical review, medical necessity, discharge planning, and post-discharge supportEnsuring compliance with State (HCA), Federal (CMS), and NCQA regulatory standardsDeveloping and implementing strategic initiatives to enhance quality-driven outcomes and meet regulatory requirementsBuilding strong relationships with key stakeholders and collaborating effectively across departmentsOverseeing key performance indicators and ensuring timely reporting to internal committees, external regulators, and leadershipWhat We’re Looking ForA Bachelor’s degree in nursing or a relevant field (Master’s degree preferred)A current unrestricted RN or ARNP license in the State of WashingtonAt least ten years of progressive UM or related managed care experience, with five years in a leadership roleExperience with Medicaid, Medicare, and DSNP programs, including knowledge of CMS and NCQA standardsStrong analytical and problem-solving skills, with the ability to drive change through data-driven decision-makingAn inclusive leadership style with a transformational spirit, open to innovative ideas and out-of-the-box thinkingAbility to build and maintain effective working relationships across departments and with external stakeholdersWhy You’ll Love Working at CHPWCompetitive salary range: $170,000 – $200,000 with 15% annual bonus potentialComprehensive benefits package, including medical, dental, vision, telehealth, flexible spending accounts, and moreOpportunities for professional growth and development in a supportive and dynamic work environmentA commitment to diversity, equity, and inclusion in all aspects of CHPW.Additional Functions and Roles and Responsibilities:Oversee the organization’s comprehensive utilization management and transitional care strategy, including integrated teams performing utilization management functions for physical and behavioral health servicesLead systematic and comprehensive utilization management programs, including written policies and procedures that ensure regulatory complianceLead transitional care programs that incorporate 72-hour post-discharge support and behavioral transitionsWork effectively across departments to ensure seamless coordination and operational workflowsShare responsibility for operational oversight of Plan Medical Directors performing utilization review functionsEnsure effective oversight of UM operations and staff, including performance management and staff developmentCollaborate with Healthcare Economics and other departments to analyze population data for variances in utilizationCollaborate with Business Process Operations (BPO) leadership to ensure alignment of Utilization Management and Claims systemsCollaborate with the Plan Medical Directors and other Clinical Services leadership to evaluate medical and behavioral utilization trendsImplement relevant components of new product lines and support quality improvement principlesOversee key performance indicators and ensure timely reporting to appropriate committees and leadershipOversee development and monitoring of annual department budgetsParticipate as an active member on assigned committeesOther duties as assigned.Knowledge, Skills, and Abilities:Familiarity with process improvement and systems thinkingExcellent customer service skills with internal and external customersHighly effective communicator orally and in writingAdvanced analytical and problem-solving skillsArticulates organizational vision and implements strategic initiativesPromotes and role-models a culture of collaboration and accountabilityPerform all functions of the job with accuracy and attention to detailNote: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.As part of our hiring process, the following criteria must be met:Complete and successfully pass a criminal background checkHas not been sanctioned or excluded from participation in federal or state healthcare programsVaccination 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. The base pay offered will consider internal equity and may vary depending on the candidate’s job-related knowledge, skills, and experience.CHPW offers the following benefits for Full and Part-time employees and their dependents:Medical, Prescription, Dental, and VisionTelehealth appFlexible Spending Accounts, Health Savings AccountsBasic Life AD&D, Short and Long-Term DisabilityVoluntary Life, Critical Care, and Long-Term Care Insurance401(k) Retirement and generous employer matchEmployee Assistance Program and Mental Fitness appFinancial Coaching, Identity Theft ProtectionTime off including PTO accrual starting at 17 days per year10 standard holidays, 2 floating holidays

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