Manager, Clinical Utilization Management & Transitions of Care

Job Description

Job Description

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.
• Create an equitable work environment.

About the Role

This position leads and oversees the team focusing on utilization management inpatient medical necessity reviews and transitions of care (TOC) efforts, including post-discharge outreach and onsite facility engagement, to support safe, timely, and effective transitions across care settings.

This leader partners closely with the broader Utilization Management team, network facilities, and vendors to develop and optimize workflows that ensure regulatory compliance, operational efficiency, and high-quality member outcomes. The role plays a key part in driving performance across clinical quality, timeliness, and care coordination while strengthening relationships with providers and improving the overall member experience.

To be successful in this role, you:

• Hold a current, unrestricted RN license in the State of Washington.
• Have a bachelor’s degree in nursing or an advanced clinical degree, or additional advanced clinical training, preferred.
• Have a minimum of three (3) years UM or CM experience required.
• Have a minimum of two (2) years in a supervisory or management role required.
• Have a minimum of six (6) years clinical experience in a medical/surgical or pediatric setting required.
• Possess a valid WA driver's license and have access to a reliable automobile.
• Have experience working in a managed care setting, including case and disease management, preferred.
• Have experience in review of behavioral health and/or substance abuse service preferred.
• Have experience with utilization management or care management workflow systems, as well as operational and utilization data, preferred.

Essential functions and Roles and Responsibilities:

• Lead and manage the daily operations of the team, including staffing and scheduling, ensuring timely completion of UM reviews and Transition of Care activities (post-discharge calls and onsite facility visits).
• Oversee TOC workflows, including 72-hour post-discharge outreach, member engagement, and coordination with inpatient and community providers to support safe transitions and reduce readmissions.
• Support and operationalize onsite facility engagement, partnering with hospitals and facilities to facilitate discharge planning, remove barriers, and improve follow-up care compliance.
• Ensure staff are trained and equipped to meet UM, TOC and engagement performance targets including clinical quality and financial outcomes.
• Establish and monitor individual and team performance goals, providing coaching and taking appropriate action to ensure that goals are achieved.
• Collaborate with the Director of Clinical Utilization Management to develop and implement initiatives, develop tactical plans, drive performance, and achieve targets.
• Ensure staff members maintain competency in UM reviews, TOC processes, and regulatory requirements.
• Promote on-going staff development through education and opportunities for professional development.
• Monitor departmental performance against key metrics (e.g timeliness, TOC compliance, readmission, quality of reviews) and implement process improvement.
• Lead and participate in departmental and interdepartmental workgroups to continually enhance the delivery of programs and services and proactively respond to changing client and market expectations.
• Ensure that all services are delivered consistently with applicable internal policies and procedures, regulatory agency requirements, and standards of practice for utilization management and transitions of care.
• Ensure processes and documentation meet NCQA and all regulatory requirements.
• Occasional travel for on-site facility visits may occur for staff onboarding, facility support, or leadership meetings in the Seattle office.
• 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).
• Ability to lead, train and motivate teams, creating a positive and efficient work environment.
• Ability to set quality and productivity goals, monitor performance and proactively address opportunities for improvement.
• Advanced analytical skills and the ability to interpret, evaluate and formulate action plans based upon data.
• Knowledge in criteria sets, including MCG preferred.
• Knowledge of utilization management and care management workflow systems.
• Effective communication and collaboration skills across multidisciplinary teams.
• Proficiency in Microsoft Office and reporting tools.
• Effective organizational, time management, and project management skills.
• High attention to detail and ability to meet deadlines.

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.
• 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. Based on market data, this position grade is 69E and has a 10% annual incentive target based on company, department, and individual performance goals. Salary determined at offer will be based on labor market data and a candidate's years of relevant work experience and skills relevant to the position.

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 pay.

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.
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion.
• Frequent torso/back static position; occasional stooping, bending, and twisting.
• Some kneeling, pushing, pulling, lifting, and carrying (not over 25 pounds), twisting, and reaching.

Mental :

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Work Environment:

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