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.
• Prepares and analyzes specific utilization management program reports and presents to applicable leadership and/or committees.
• Manages program/vendor relationships.
• Develops and implements workflows for system integration and quality assurance.
• Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Knowledge of regulatory and certification requirements and their impact on the organization (for example, HEDIS, CAHPS, and NCQA).
• Experience in utilization management workflow systems.
• Effective verbal and written communication skills
• Flexibility and willingness to work in a matrix-management environment.
• Demonstrated organizational, time management, and project management skills.
• Ability to multi-task and handle complex assignments on a frequent basis.
• Demonstrated proficiency and experience with Microsoft Office products.
• Ability to work independently.
• Ability to present in a group setting.
• Performs all functions of the job with accuracy, attention to detail and within established timeframes.
• Meets attendance and punctuality standards.
• Demonstrates professional courtesy to others and ability to maintain confidentiality.

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. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency.
• 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 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

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

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking and possibly standing
• Frequent finger dexterity; occasional simple grasp and wrist flexion
• Constant walking or climbing stairs.
• Occasional stooping, bending, and twisting.
• Frequent kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental:

• Frequent decision-making. Ability to gather and assess data, determine appropriate actions, apply protocols and knowledge to unique situations, problem-solve and provide consultation.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.