Manager, Clinical Utilization Management – Transitions of Care

This is a fully remote position, open to applicants in Washington.

📋 Description

• Oversee and manage the daily operations of the department, which includes staffing and scheduling, while ensuring the timely completion of UM reviews and Transition of Care activities such as post-discharge calls and onsite facility visits.

• Supervise TOC workflows, which encompass 72-hour post-discharge outreach, member engagement, and collaboration with inpatient and community providers to ensure safe transitions and minimize readmissions.

• Facilitate onsite facility engagement by partnering with hospitals and facilities to enhance discharge planning, eliminate barriers, and improve compliance with follow-up care.

• Ensure that staff are properly trained and equipped to meet performance targets for UM, TOC, and engagement, focusing on both clinical quality and financial outcomes.

• Set and monitor individual and team performance objectives, providing coaching and taking necessary actions to ensure goal attainment.

• Work alongside the Director of Clinical Utilization Management to create and execute initiatives, develop tactical plans, drive performance, and meet targets.

• Ensure that staff maintain competency in UM reviews, TOC processes, and comply with regulatory requirements.

• Foster ongoing staff development through educational opportunities and professional growth initiatives.

• Track departmental performance against key metrics (e.g., timeliness, TOC compliance, readmission rates, quality of reviews) and implement process improvements accordingly.

• Lead and engage in departmental and interdepartmental workgroups to continuously enhance program and service delivery while proactively addressing evolving client and market expectations.

• Ensure all services are provided in accordance with applicable internal policies and procedures, regulatory agency requirements, and standards of practice for utilization management and transitions of care.

• Ensure that processes and documentation comply with NCQA and all relevant regulatory requirements.

• Occasional travel for onsite visits may be necessary for staff onboarding, facility support, or leadership meetings at the Seattle office.

⛳️ Requirements

• Must possess a current, unrestricted RN license in the State of Washington.

• A bachelor's degree in nursing or an advanced clinical degree, or additional advanced clinical training is preferred.

• At least three (3) years of experience in UM or CM is required.

• A minimum of three (3) years in a leadership role is required, with experience managing remote teams preferred, or three (3) years in a supervisory or management capacity.

• A minimum of three (3) years of acute or ambulatory clinical experience in a medical/surgical or pediatric environment is required.

• Must hold a valid WA driver's license and have access to a reliable vehicle.

• Experience in a managed care environment, particularly in case and disease management, is preferred.

• Experience in reviewing behavioral health and/or substance abuse services is preferred.

• Familiarity with utilization management or care management workflow systems, as well as operational and utilization data, is preferred.

🏝️ Benefits

• Medical, Prescription, Dental, and Vision coverage.

• Access to a Telehealth application.

• Flexible Spending Accounts and Health Savings Accounts.

• Basic Life AD&D, Short and Long-Term Disability coverage.

• Optional Life, Critical Care, and Long-Term Care Insurance.

• 401(k) Retirement plan with a generous employer match.

• Employee Assistance Program and Mental Fitness application.

• Financial Coaching and Identity Theft Protection services.

• Generous time off, including PTO accrual starting at 17 days per year.

• 40 hours of Community Service volunteer time.

• 10 standard holidays and 2 floating holidays.

• Compassionate leave and jury duty pay.