Clinical Nurse Specialist (Nurse Informaticist) (CNSCQCT)

Description

Clinical Nurse Specialist (Nurse Informaticist)

This is a full-time permanent remote position. Employees may occasionally be asked to attend an in-person meeting or event based on business needs.

All HCA employees are required to be Washington state residents upon their first day of employment.

The Opportunity

Help shape how Washington Medicaid connects clinical care and technology. The Clinical Quality and Care Transformation (CQCT) division is seeking a Clinical Nurse Specialist with nurse informatics expertise to lead HCAs implementation of state and federal prior authorization interoperability requirements including HB 1357 (as amended by HB 1706) and CMS-0057-F. You will apply your clinical judgment and informatics knowledge to design and refine the systems workflows and policies that make prior authorization decisions more efficient while ensuring Apple Health clients receive medically necessary high-quality care.

Key Responsibilities Include:

• Lead oversight and implementation of the information exchange components of state and federal legislation regarding prior authorization and Application Programming Interface (API) for HCA and Medicaid.
• Coordinate with HCA divisions payers and provider electronic health record (EHR) and practice management systems to identify prior authorization documentation requirements and support standard automated data exchange using nonproprietary open workflows.
• Guide the configuration of new and existing Medicaid clinical policies into payment systems and serve as HCAs subject matter expert on prior authorization provider directory patient access and other interoperability initiatives.
• Represent the Washington State Medicaid perspective in CMS rulemaking and in forums such as the Workgroup for Electronic Data Interchange (WEDI).
• Conduct utilization reviews and make prior authorization and claim payment determinations using evidence-based clinical policy and the requirements of WAC .
• Review reconsideration requests prepare the agencys position for administrative hearings and provide declarations or testimony as needed.
• Apply annual and quarterly CPT and HCPCS code updates to clinical policies provider guides and provider notices.
• Analyze prior authorization and API metrics for state and federal reporting and advise leadership on new or modified policy and regulations including cost and utilization impacts.
• Negotiate and monitor contracts support bill analysis and decision packages and serve as a liaison with DSHS the Department of Health the Department of Corrections and provider groups.

Why Youll Love This Role:

• Your nursing expertise will have statewide reach helping Apple Health clients get timely access to the care they need.
• Youll be at the forefront of health care interoperability helping Washington put national data standards like FHIR into everyday practice.
• Youll reduce administrative burden on clinicians across the state freeing more of their time for patient care.
• Youll work remotely with flexible scheduling options as part of a clinical team that values innovation and evidence-based practice.

What You Bring:

You are a curious systems-minded nurse who is as comfortable reviewing a complex medical record as you are talking through data standards with a technical team. You make sound independent clinical decisions and explain your reasoning clearly whether in a provider letter a leadership briefing or a hearing. You build bridges between clinicians technologists and policy staff translating each groups needs so the work can move forward. You stay current on emerging regulations and technology and enjoy sharing what you know with others.

Required Qualifications

Experience may have been gained through paid or unpaid activities. Please ensure any relevant experience defined below is outlined in your cover letter resume and application.

• An active unrestricted Washington State Registered Nurse license or Multi-State License.
• Interoperability & Health Information Technology (HIT)
  • API & Data Standards Expertise: Deep technical understanding of Application Programming Interfaces (APIs) HL7 and Fast Healthcare Interoperability Resources (FHIR) standards specifically as they apply to patient access provider directories and prior authorization.
  • Electronic Health Record (EHR) Integration: Demonstrated ability to align complex provider EHRs and practice management systems with state payer databases.
  • Workflow Automation: Demonstrated ability to design and implement standard nonproprietary open workflows that automate data collection and reduce administrative burdens for clinicians.
• Regulatory Compliance & Policy Leadership
  • Legislative Interpretation: Demonstrated mastery in interpreting and operationalizing federal Centers for Medicare & Medicaid Services (CMS) rulemaking and state regulations specifically Washington Administrative Codes (WACs).
  • Policy Formulation: Demonstrated ability to advise executive leadership Medical Directors and/or division heads on the financial and clinical utilization impacts of new or modified health care regulations.
• Advanced Utilization Review & Clinical Evaluation
  • Evidence-Based Medical Necessity: Demonstrated competency in independently evaluating complex medical records against scientific evidence to make highly defensible prior authorization and claim payment determinations.
  • Administrative Hearing Defense: Demonstrated skills in preparing organizational position statements drafting legal declarations and delivering expert clinical testimony during formal appeals and utilization review denial hearings.
• System Leadership & Change Management
  • Cross-Functional Liaison: Demonstrated ability to serve as a high-level intermediary bridging the technical and clinical communication gaps between agencies commercial payers and community health care providers.
• Contract & Resource Management
  • Contract Monitoring: Demonstrated ability to successfully negotiate structure and monitor health care and technology vendor contracts to ensure agency alignment.
• Clinical Education & Mentorship
  • Subject Matter Expertise: Demonstrated ability to serve as the definitive accessible clinical resource for all internal and external inquiries regarding assigned Medicaid clinical programs.

Required Competencies:

• Equity lens All HCA employees are required to consider equity in their decisions processes and day-to-day work including how their work may affect the people and communities we serve.

• The ability to take action to learn and grow You take action to learn and grow by seeking new perspectives learning from experiences and using what youve learned to continuously improve how you work and serve others.

• The ability to take action to meet the needs of others You take action to meet the needs of others by listening understanding different perspectives and responding with care respect and solutions that support the people of the communities we serve.

Preferred Qualifications

While these are not required having them may help you stand out as an applicant.

• National Coding Systems: Demonstrated proficiency in translating annual and quarterly CPT and HCPCS codes into active Medicaid policies provider guides and billing systems.
• Continuous Quality Improvement (CQI): Demonstrated mastery in reviewing prior authorization and API metrics data to identify systemic gaps generate federal reports and lead intra-agency care delivery updates.
• Alternative Care Negotiation : Demonstrated ability to consult with community providers to propose and negotiate alternative covered and more cost-effective treatment pathways that still meet the patients clinical needs.
• A masters degree in nursing (MSN or MN) business administration (MBA) or health administration (MHA).
• Certification in informatics (RN-BC in Informatics or CPHIMS).
• Knowledge of HCA structure systems communication methods and forms.

About Clinical Quality and Care Transformation (CQCT)

The mission of Clinical Quality and Care Transformation (CQCT) is to provide high-quality health care through innovative health policies and purchasing strategies that assist in the purchase and delivery of health care services to qualified Washington residents. CQCT staff work across the agency and with other agencies such as the Department of Health and the Department of Social and Health Services and in partnership with health care providers and community partners to develop implement and manage high-quality evidence-based health care programs that enhance clients ability to access appropriate quality health care.

Supplemental Information

The Washington State Health Care Authority:

Better Health. Better Care. A Healthier Washington.

At HCA we work to ensure people across Washington have the opportunity to be as healthy as possible. As the States largest health care purchaser and behavioral health authority HCA serves nearly 3 million Washington residents through Apple Health (Medicaid) Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs and behavioral health services. Through this work HCA purchases and coordinated care coverage supports behavioral health prevention treatment crisis response and recovery and helps strengthen access to high -quality care across Washington.

More than a benefits package:

We want our employees to have the support flexibility and benefits they need to do their best work and build a career that works for their life. As a Washington State HCA employee youll have access to a comprehensive benefits package that supports your health financial well-being and work-life balance. Our benefits are designed to support you today while helping you plan for the future. Learn more about why HCA by visiting the Voices of HCA and the Who we are section of our website.

Your total compensation is more than your paycheck:

• Remote work and flexible schedules
• Medical dental vision and basic life insurance
• Paid vacation sick leave and 12 paid holidays
• Paid Family and Medical Leave (PMFL)
• Retirement options to plan for the future
• Training and professional development opportunities
• Employee wellness programs
• Learn more about Washington State Employee Benefits

Work Location and Schedule:

This is a full-time 40-hour-per-week remote position. Our standard business hours are Monday through Friday 8 a.m. to 5 p.m. with alternative work schedules considered based on business needs and supervisor this role you will regularly collaborate with colleagues agency leaders state and federal partners and other external partners or customers. Occasional travel may be required for meetings training or other business needs. All employees are required to report to our Olympia office on their first and final day of employment.

Our commitment to an inclusive workplace

The Health Care Authority is an equal opportunity employer. We are committed to creating a workplace where employees are respected included and supported in bringing their experiences perspectives and ideas to work.

Our commitment to inclusion is reflected in how we work together and serve the people of Washington. HCA also supports five voluntary employee led Employee Resources Groups (ERGs) which create opportunities for connection community learning and professional growth.

Application Directions :

To be considered you must complete the online application in full and submit all required materials. Incomplete applications or applications missing required materials will not be considered. When completing your application please include the following required materials:

• Cover letter: describing your qualifications for this specific position
• Resume: that details your applicable experience and education.
• Three (3) professional references: References must be entered directly into the designated references section of your application. We require 3 professional references including at least one current or recent supervisor.

We encourage you to apply! If you meet the required qualifications for this position; we want to hear from you. Desired qualifications describe additional experience knowledge or skills that may be helpful in the role but they are not required to be considered for the position. We welcome applicants with different backgrounds experiences identities and perspectives.

Veterans

We value the experience and skill veterans bring to the workforce and encourage veterans transitioning service members and military spouses to apply. Eligible veterans may qualify for veterans preference in accordance with Washington State Law. If you are claiming veterans preference you must attach your applicable DD-214 documentation to your application. Please redact your social security number date of birth and any other sensitive information before uploading and attaching the document.

Need accommodations or have questions If you have questions need assistance with the application process require an accommodation or would like to request this posting in an alternative format please contact Lisa Fleming Human Resources Consultant (Recruiter) at and reference the recruitment title and job number in the subject line.

Technical Support : Reach out to NEOGOV directly at 1- for technical support and login issues.

The Washington State Health Care Authority (HCA) is an E-Verify employer. All applicants with a legal right to work in the United States are encouraged to apply.

E-Verify is a registered trademark of the U.S. Department of Homeland Security.

Required Experience:

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