Community Health Plan of Washington (CHPW)
Sr Dir Utilization Management & Transitional Care
Community Health Plan of Washington (CHPW), New York, New York, United States,
Morgan Consulting Resources, Inc.
has been retained by
Community Health Plan of Washington
to conduct the search for an innovative and experienced leader to join their team as
Senior Director, Utilization Management & Transitional Care . This is a remote position (WA/OR/ID) with periodic travel to the home office in Seattle.Why join Community Health Plan of Washington?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 support.Ensuring compliance with State (HCA), Federal (CMS), and NCQA regulatory standards.Developing and implementing strategic initiatives to enhance quality-driven outcomes and meet regulatory requirements.Building strong relationships with key stakeholders and collaborating effectively across departments.Overseeing key performance indicators and ensuring timely reporting to internal committees, external regulators, and leadership.What 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 Washington.At least ten years of progressive UM or related managed care experience, with five years in a leadership role.Experience with Medicaid, Medicare, and DSNP programs, including knowledge of CMS and NCQA standards.Strong analytical and problem-solving skills, with the ability to drive change through data-driven decision-making.An inclusive leadership style with a transformational spirit, open to innovative ideas and out-of-the-box thinking.Ability to build and maintain effective working relationships across departments and with external stakeholders.Why You’ll Love Working at CHPWCompetitive salary range: $170,000 - $200,000 with 15% annual bonus potential.Comprehensive benefits package, including medical, dental, vision, telehealth, flexible spending accounts, and more.Opportunities for professional growth and development in a supportive and dynamic work environment.A 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.Lead systematic and comprehensive utilization management program that incorporates intake, clinical review, medical necessity, discharge planning, and post-discharge support.Lead transitional care program that incorporates 72-hour post-discharge support and behavioral transitions.Work effectively across departments to ensure seamless coordination and operational workflows.Share responsibility for operational oversight of Plan Medical Directors performing utilization review functions.Ensure effective oversight of UM operations and staff.Collaborate with Healthcare Economics and other departments to analyze the Plan population data for variances in utilization.Collaborate with Business Process Operations (BPO) leadership to ensure Utilization Management and Claims systems are in alignment.Work collaboratively with the Plan Medical Directors, Pharmacy department, and other Clinical Services leadership to evaluate medical and behavioral utilization trends.Successfully implement relevant components of new product lines.Oversee key performance indicators and ensure timely reporting to appropriate internal committees and leadership.Oversee development and monitoring of annual department budgets.Participate as an active member on committees as assigned.Other duties as assigned.Knowledge, Skills, and Abilities:Familiarity with process improvement and systems thinking.Excellent customer service skills.Highly effective communicator orally and in writing.Advanced analytical and problem-solving skills.Ability to articulate organizational vision and implement strategic initiatives.Promote and role-model a culture of collaboration and accountability.Perform all functions of the job with accuracy and attention to detail.Note: 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 check.Criminal History:
includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment.Has not been sanctioned or excluded from participation in federal or state healthcare programs.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 and has a 15% 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.
#J-18808-Ljbffr
has been retained by
Community Health Plan of Washington
to conduct the search for an innovative and experienced leader to join their team as
Senior Director, Utilization Management & Transitional Care . This is a remote position (WA/OR/ID) with periodic travel to the home office in Seattle.Why join Community Health Plan of Washington?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 support.Ensuring compliance with State (HCA), Federal (CMS), and NCQA regulatory standards.Developing and implementing strategic initiatives to enhance quality-driven outcomes and meet regulatory requirements.Building strong relationships with key stakeholders and collaborating effectively across departments.Overseeing key performance indicators and ensuring timely reporting to internal committees, external regulators, and leadership.What 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 Washington.At least ten years of progressive UM or related managed care experience, with five years in a leadership role.Experience with Medicaid, Medicare, and DSNP programs, including knowledge of CMS and NCQA standards.Strong analytical and problem-solving skills, with the ability to drive change through data-driven decision-making.An inclusive leadership style with a transformational spirit, open to innovative ideas and out-of-the-box thinking.Ability to build and maintain effective working relationships across departments and with external stakeholders.Why You’ll Love Working at CHPWCompetitive salary range: $170,000 - $200,000 with 15% annual bonus potential.Comprehensive benefits package, including medical, dental, vision, telehealth, flexible spending accounts, and more.Opportunities for professional growth and development in a supportive and dynamic work environment.A 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.Lead systematic and comprehensive utilization management program that incorporates intake, clinical review, medical necessity, discharge planning, and post-discharge support.Lead transitional care program that incorporates 72-hour post-discharge support and behavioral transitions.Work effectively across departments to ensure seamless coordination and operational workflows.Share responsibility for operational oversight of Plan Medical Directors performing utilization review functions.Ensure effective oversight of UM operations and staff.Collaborate with Healthcare Economics and other departments to analyze the Plan population data for variances in utilization.Collaborate with Business Process Operations (BPO) leadership to ensure Utilization Management and Claims systems are in alignment.Work collaboratively with the Plan Medical Directors, Pharmacy department, and other Clinical Services leadership to evaluate medical and behavioral utilization trends.Successfully implement relevant components of new product lines.Oversee key performance indicators and ensure timely reporting to appropriate internal committees and leadership.Oversee development and monitoring of annual department budgets.Participate as an active member on committees as assigned.Other duties as assigned.Knowledge, Skills, and Abilities:Familiarity with process improvement and systems thinking.Excellent customer service skills.Highly effective communicator orally and in writing.Advanced analytical and problem-solving skills.Ability to articulate organizational vision and implement strategic initiatives.Promote and role-model a culture of collaboration and accountability.Perform all functions of the job with accuracy and attention to detail.Note: 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 check.Criminal History:
includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment.Has not been sanctioned or excluded from participation in federal or state healthcare programs.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 and has a 15% 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.
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