Community Health Plan of Washington

Manager

• This position works under the general direction of the Supervisor of Care Management and is responsible for the plan’s regional field care management and coordination programs and processes.
• The Regional Field Case Manager will provide care management services for CHPW members with short term, long term, stable, unstable, and predictable course of illness.
• The Regional Field Case Manager resides within the assigned region to effectively coordinate care between members, providers and community resources.
• This role also provides care management services for CHPW members with highly complex medical/behavioral and social conditions where advocacy and coordination are required.
• This role represents CHPW in the community to provide education on care management programs and provide in-person support for members.
• The Regional Field Case Manager coordinates with internal and external partners to support members, providers and initiatives in the assigned region.

Regional Field Case Manager I, MSW/RN

General

• Performs data entry for all referral, prior authorizations and hospital notifications; attaches and/or includes clinical documents as needed
• Utilizes knowledge to determine appropriate CPT, HCPC, ICD-10 codes using CMS, NCQA and HCA criteria
• Researches and validates benefit and prior authorization requirements to determine appropriate course of action within the Care Management system
• Reviews, corrects, and approves authorization requests via the web portal; determines appropriate level of complexity and refers cases requiring clinical review to a nurse reviewer
• Reviews completed denial letters for accuracy and adherence to compliance deadlines
• Edits and proofreads content for appropriate medical terminology and MCG criteria
• Ensures letters are mailed within established timeframes
• Accurately applies policies & procedures, benefit and eligibility standards to all incoming requests
• Conducts research, validates data, and responds to complex inquiries from multiple sources, including but not limited to members, nurses, medical providers, customer service, operations, appeals, case management and care coordination

Utilization Management Coordinator

Clinician

• The Level I Utilization Management Clinician performs utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools.
• Identifies, coordinates, and implements high quality, cost-effective alternatives when appropriate to the patient’s condition.
• Supports physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes.
• Ensures members have timely access to care and supports during transitions between levels of care.
• Understands and effectively communicates requirements and follows Community Health Plan of Washington (CHPW) policies and procedures.

Behavioral Health Utilization Management Clinician I – RN

• Responsible for the operational delivery of the plan’s case management and coordination programs and processes.
• Provides case management services for CHPW members with short term, long term, stable, unstable, and predictable course of illness, and/or highly complex medical/behavioral and social conditions.
• The goal is to improve members' quality of life and ensure cost-effective outcomes by using internal and community-based resources.
• Advocates on behalf of members and facilitates coordination of resources required to help members reach optimum functional levels and autonomy within the constraints of their disease conditions.
• Works within a multi-functional team to connect with providers, members, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes.
• Assesses, evaluates, plans, implements, and documents care of members within the organization’s clinical database system, in accordance with organizational policies and procedures.
• Responsible for the assessment of members, including identifying and coordinating access to the appropriate level of care and treatment.
• Uses the assessment information to assign the appropriate risk and complexity level, and create and document a care plan in coordination with the member, family and health team input.
• Initiates a plan of care based on member-specific needs, assessment data and the medical/behavioral plan of care.
• Goals for members are measurable and developed in conjunction with the patient/family to improve quality of life.
• Plans care in collaboration with members of the multidisciplinary team, and considers the physical, behavioral, cultural, psychosocial, spiritual, age specific and educational needs of the member in the plan of care.
• Reviews and revises the plan of care with the interdisciplinary care team to reflect changing member needs based on evaluation of the members’ status, and/or as a result of reassessment.
• Implements the plan of care through direct member care, coordination, and delegation of the activities of the health care team.
• Promotes continuity of care by accurately and completely communicating to health care team the status of members for whom care is provided.
• Engages community resources where applicable.
• Conducts interdisciplinary care team meetings with the member/family to assess care plan and recommend adjustments as indicated.
• Continuously evaluate members’ progress towards goals, identify potential barriers to attaining goals and expected outcomes in collaboration with other health care team members.
• Documents all case activity using the CHPW care management system and follows documentation standards and protocols.
• Collaborates with the Transition of Care (TOC) team if a member is hospitalized.
• Serves as a liaison at various local and statewide meetings and/or workgroups and provides clinical support to providers’ network to enhance integrated care coordination.
• Assesses barriers to care and assist members and health care team to address concerns.
• Implements developed workflow activities and activities for designated programs.
• Conduct member case management in the field at Provider(s) office, member’s home, inpatient medical or psychiatric hospitals, skilled nursing facilities, adult family homes, or in a community setting.
• Attend member appointments or care conferences in collaboration with the members care team when indicated.
• This position may requires traveling on behalf of the Company and working in the field.
• Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.
• Other duties as assigned.

Case Manager I – MSW/RN, Medicare/DSNP

Clinical Care Coordinator

• Assists with and coordinates care management activities under the direction of an RN or LICSW Case Manager, Supervisor, or Manager
• Functions as an interdependent team member in the areas of member assessment, planning, facilitation, and advocacy
• Communicates with providers to arrange follow up appointments, obtain clinical records, and assist members with care coordination
• Ensures appropriate coordination of services to members such as any necessary member transportation needs, obtaining community resources such as food pantries and housing
• Coordinates and facilitates services with physical and behavior health care providers within an episode of care
• Documents and manages the care management process to include case identification, assessment, planning and goal prioritization, monitoring, support, and case closure
• Participates in clinical outcome data monitoring and collection
• Assesses member health care status and health (medical, behavioral, and social) history, risks, gaps and utilization
• Develops plans of care with appropriate member centric interventions
• Provides behavioral health support and interventions to members in crisis
• Collaborates with member PCP, specialists, and community resources/vendors to leverage community resources
• Ensures all care coordination activities are documented medical record system per established guidelines
• Support staff in answering member calls including participation in the 5pm call rotation for crisis calls

Clinical Care Coordinator, LPN/BSW

• Identifies, locates, and determines custody status of Apple Health Fee-for-Service justice involved members.
• Advocates on behalf of and facilitates coordination of resources required to help justice involved members reach optimum functional levels upon reentry to the community during transition and provides short-term case management.
• Works with the city and county jails, Department of Corrections facilities, and Juvenile Rehabilitation facilities and a multi-functional team to connect with providers, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes upon reentry to the community.
• Performs the primary functions of assessment, planning, facilitation, and advocacy through collaboration with the member, city and county jails, Department of Corrections, and Juvenile Rehabilitation facilities and other health care resources involved in the member's transition post-release.
• Meets with the justice involved members via phone or video conferencing at city and county jails, Department of Corrections, and Juvenile Rehabilitation facilities.
• Documents all case activity using the CHPW care management system and follows documentation standards and protocols.
• Participates in telephonic/and or video discharge planning meetings and interdisciplinary care conferences, when appropriate and necessary.
• Schedules medical, mental health, dental, and/or vision appointments in accordance with the member’s release date.
• Schedule transportation to appointments if required.
• Conducts comprehensive social determinants of health (SDoH) assessments and coordinates care plan needs to address identified gaps.
• Communicates with the members pertinent providers to discuss discharge plans and provide updates on status.

Transitions of Care Manager

Community Health Worker

• Support a successful transition from the carceral setting to the community
• Identify barriers to healthcare and social services and connect members to resources to optimize the members health
• Collaborate with the Carceral Transitions team, facility staff and community to ensure a success re-entry into the community for the member
• Build individual and community capacity by increasing health knowledge and self-sufficiency through outreach, community education and referrals, peer support and advocacy
• Advocate on behalf of and facilitate coordination of resources required to help justice involved members reach optimum functional levels upon reentry to the community during transition and provides short-term care coordination
• Communicate the members health care needs with the carceral facility and send medical records if required
• Identify Health Related Social Needs and connect members to appropriate community resources
• Meet with the members via phone or video conferencing at city and county jails, or the Department of Corrections
• Coordinate medical, dental, and/or vision appointments in accordance with the members release date including transportation to appointments if required
• Provide verbal and/or written status updates regarding the members progress and needs to responsible case managers and providers, legal mandate, or other care plan affiliates as needed to assist the program and members
• Ensure case documentation is consistent with policies and procedures
• Complete Health Risk Assessments with members

Community Health Worker – Carceral Transitions

• Perform utilization review for medical or behavioral health requests using utilization review criteria, technologies, and tools.
• Identify, coordinate, and implement high quality, cost-effective alternatives when appropriate to the patient’s condition.
• Support physician decision-making, working collaboratively with all members of the health care team, the patient, the patient’s family, co-workers, and internal and external customers to achieve optimal patient outcomes.
• Ensure members have timely access to care and supports during transitions between levels of care.
• Conduct review of hospital notification or prior authorization care requests against established clinical guidelines and health plan policies.
• Conduct onsite visits to local facilities 1-3 times weekly to connect with members and support successful post-discharge transitions.
• Collaborate with facilities to perform discharge planning.
• Provide coordination support to members transitioning between care settings or returning home from a hospitalization.
• Identify member needs and provide support to ensure necessary services are available during the transition period.
• Collaborate with providers, office staff, and Care Coordination team to assure coordination of care in a timely manner according to contractual and regulatory timeframes.
• Identify, coordinate, and ensure high quality care and appropriate care by focusing on supporting access to care and services across the continuum of care in accordance with the patient’s medical needs.

Utilization Management Clinician I

Clinical Operations

• Develop and foster relationships with senior Care Management leadership through ongoing collaboration on process improvement initiatives related to operational efficiency, workflow management, and analytical support.
• Oversee departmental projects, including identifying initiatives, developing project plans and timelines, and managing project work through completion.
• Lead interdepartmental meetings, serving as a subject matter expert and educator to promote cross functional understanding of Care Management workflows and processes.
• As needed, oversee and conduct regular internal audits of clinical staff performance, evaluating adherence to Care Management standards, regulatory requirements, and organizational policies, and provide feedback on performance gaps to staff leadership.
• Ensure Care Management training meets all standards set forth by the National Committee for Quality Assurance, Healthcare Authority, Centers for Medicare and Medicaid Services, and other applicable regulatory bodies.
• Collaborate with leadership to develop and implement new programs and enhance existing programs, including participation in and leadership of division-level initiatives in addition to Care Management-specific activities
• Participate in internal cross functional teams to ensure care management programs meet regulatory and compliance requirements.
• Serve as a resource and support for more junior Program Managers, delegating responsibilities as appropriate to help broaden team skillsets and balance work efforts within the department.
• Serve as a liaison between data analytics staff and Care Management leadership to develop or modify care management reports used to assess productivity and program outcomes.
• Produce care management reports and present findings to applicable leadership and or committees.
• Identify opportunities to standardize and improve care management processes and partner with leadership and staff to implement efficient desk procedures across lines of business.
• Perform other duties as assigned.

Program Manager III, Clinical Operations

Bilingual

• Responsible for supporting CHPW’s Medicaid, Cascade Select, and Dual Special Needs Plan (DSNP) members in navigating benefits and health care systems to promote optimal health and a positive experience with the Health Plan
• Conduct new member outreach such as welcome calls and Health Risk Assessments, as well as routine outreach to complete annual Health Risk Assessments, promote health screenings and engage members in the Care Management programs
• May serve as a primary contact for the Care Teams, receiving inbound calls from members to resolve members needs or triage to the appropriate CHPW staff or team
• Conduct telephonic outreach to identified members to complete Welcome Calls, member satisfaction surveys, and Health Risk Assessments (HRAs)
• Educate members on accessing benefits, routine health screenings, program requirements (e.g., face-to-face visits, individualized care plans, interdisciplinary care team meetings), and how to engage with the Care Team
• Schedule and coordinate in-home assessments with Community Health Workers (CHWs), and telehealth or in-person provider visits with participating Community Health Centers (CHCs)
• Support members in closing care gaps and scheduling appointments with community or in-home providers
• Triage inbound calls from members, families, and caregivers; resolve issues or refer to appropriate staff
• Participate in Care Team meetings and interdisciplinary team (ICT) conferences to support member care

Care Advocate, Bilingual Desired

Network Engineer

• This position is responsible for provider network performance analysis, development of provider monitoring of network data elements and standards to ensure network capacity, to include Behavioral Health provider access.
• The role partners with cross functional teams to deliver insights that support network strategy.
• Leads network performance analytics, including KPI trend analysis, network access and adequacy analysis, and identification of network gaps and improvement opportunities.
• Develops and maintains model to assess and monitor Community Health Plan network performance and development strategies, ensuring alignment with organizational goals.
• Collaborates with subject matter experts to track key performance indicators, identify trends and recommend interventions for network improvement.
• Analyzes demographic and utilization data, providing insights to support regulatory filings and identify opportunities for network expansion.
• Monitor Medicare network to identify access and gap issues and provide analysis for resolution in support of monthly reporting and annual CMS network and exception process submissions.
• Maintains plan HSD tables and monthly Medicare reporting according to CMS standards, researching data discrepancies to correct identified issues when applicable.
• Responsible for submission of Provider Network Form A Certification letter to the OIC, to include monitoring files being available for auto-submission by IT.
• Collaborate on contracting provider data gaps to ensure reliability, completeness, and consistency.
• Analyzes Behavioral Health network and outreach in support of Quarterly HCA Provider Network Submission, to include regular review of geographic/service coverage of Behavioral Health Agencies.
• Supports Behavioral Health AADR process through data analysis and reporting, in alignment with contract department review.
• Develops Mental Health Assessment utilizing claims information and compilation of data sets to support analysis.

Provider Network Analyst

Compliance

• This position is responsible for coordination and execution of provider network regulatory deliverables and compliance activities, including oversight of reporting processes, submission timelines and regulatory requirements.
• The role partners with internal stakeholders to ensure accurate, timely and compliant submissions, including Behavioral Health network reporting, performance improvement and regulatory readiness.
• Performs daily troubleshooting to ensure and provide timely responses to agency inquiries and requests, coordinating with relevant departments and stakeholders for resolution of objections from regulatory entity.
• Develops project status reports and business requirements for internal stakeholders on a regular basis.
• Develops and maintains model to assess and monitor Community Health Plan network development strategies, ensuring alignment with organizational goals.
• Collaborates with subject matter experts to track key performance indicators, identify trends and recommend interventions for network improvement.
• Analyzes demographic and utilization data to support regulatory filings and identify opportunities for network expansion.
• Sub-division coordination and planning of TEAMonitor narratives, supporting documentation, timelines, communications and QA processes.
• Monitor Behavioral Health network and outreach in support of Quarterly HCA Provider Network Submission, to include regular review of geographic/service coverage of Behavioral Health Agencies.
• Maintains Behavioral Health AADR process and project plan development quarterly in alignment with contract department review.
• Develops of Mental Health Assessment utilizing claims information and compilation of data sets to support analysis.
• Coordinates resolution of contracting provider data gaps impacting regulatory submissions, ensuring reliability, completeness, consistency and compliance.
• Develops and maintains processes to track and manage regulatory deliverables, resolving issues to ensure accuracy of narratives and data submissions, to include TEAMonitor coordination and HCA contract reviews.
• Collaborates across departments and teams to initiate and deliver projects that advance network strategy and fosters interdepartmental partnerships.

Performance and Network Compliance Analyst

• Responsible for the operational delivery of the plan’s case management and coordination programs and processes
• Provide case management services for CHPW prediabetic and diabetic members
• Perform telephonic case management for members with acute, chronic, and complex needs
• Advocate on behalf of members and facilitate coordination of resources
• Assess, evaluate, plan, implement, and document care of members within the organization’s clinical database system
• Initiate a plan of care based on member-specific needs
• Collaborate with members of the multidisciplinary team
• Conduct member case management in the field at various settings including member’s home or in a community setting
• Continually evaluate members’ progress towards goals and identify barriers to attaining goals

Case Manager, Diabetes Care Program – RN Preferred

• Responsible for the operational delivery of the plan’s case management and coordination programs and processes.
• Provides case management services for CHPW members with short term, long term, stable, unstable, and predictable course of illness, and/or highly complex medical/behavioral and social conditions.
• The goal is to improve members' quality of life and ensure cost-effective outcomes by using internal and community-based resources.
• The Case Manager level will be determined by the hiring manager based on education, previous experience, and demonstrated leadership skills.
• Advocates on behalf of members and facilitates coordination of resources required to help members reach optimum functional levels and autonomy within the constraints of their disease conditions.
• Works within a multi-functional team to connect with providers, members, caregivers, contracted vendors, community resources, and health plan partners to assess the member's health status, identify care needs and ensure access to appropriate services to achieve positive health outcomes.
• Assesses, evaluates, plans, implements, and documents care of members within the organization’s clinical database system, in accordance with organizational policies and procedures.
• Responsible for the assessment of members, including identifying and coordinating access to the appropriate level of care and treatment.
• Uses the assessment information to assign the appropriate risk and complexity level, and create and document a care plan in coordination with the member, family and health team input.
• Initiates a plan of care based on member-specific needs, assessment data and the medical/behavioral plan of care.
• Goals for members are measurable and developed in conjunction with the patient/family to improve quality of life.
• Plans care in collaboration with members of the multidisciplinary team, and considers the physical, behavioral, cultural, psychosocial, spiritual, age specific and educational needs of the member in the plan of care.
• Reviews and revises the plan of care with the interdisciplinary care team to reflect changing member needs based on evaluation of the members’ status, and/or as a result of reassessment.
• Implements the plan of care through direct member care, coordination, and delegation of the activities of the health care team.
• Promotes continuity of care by accurately and completely communicating to health care team the status of members for whom care is provided.
• Engages community resources where applicable.
• Conducts interdisciplinary care team meetings with the member/family to assess care plan and recommend adjustments as indicated.
• Continuously evaluate members’ progress towards goals, identify potential barriers to attaining goals and expected outcomes in collaboration with other health care team members.
• Documents all case activity using the CHPW care management system and follows documentation standards and protocols.
• Collaborates with the Transition of Care (TOC) team if a member is hospitalized.
• Serves as a liaison at various local and statewide meetings and/or workgroups and provides clinical support to providers’ network to enhance integrated care coordination.
• Assesses barriers to care and assist members and health care team to address concerns.
• Implements developed workflow activities and activities for designated programs.
• Conduct member case management in the field at Provider(s) office, member’s home, inpatient medical or psychiatric hospitals, skilled nursing facilities, adult family homes, or in a community setting.
• Attend member appointments or care conferences in-person in collaboration with the members care team when indicated.
• This position may require traveling on behalf of the Company and working in the field.
• Employees are expected to report to work as scheduled, participate in all assigned meetings, and meet established performance and accountability standards.
• Other duties as assigned.