Community Health Plan of Washington

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

Manager

• 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.

Case Manager I, MSW/RN

Product Manager

• Serve as product owner and primary point of contact for assigned clinical systems, managing backlog prioritization and alignment to objectives while fostering strong cross-functional and vendor partnerships.
• Translate business and clinical needs into clear product deliverables (e.g., epics, user stories, acceptance criteria, and release plans) that enable predictable delivery.
• Lead Agile delivery execution with Technical Program Managers and delivery teams, overseeing planning, coordination, progress tracking, and retrospectives, while ensuring alignment to scope, schedule, and quality commitments and proactively managing risks, dependencies, and escalations.
• Lead UAT and release readiness activities, ensuring solutions meet quality and operational standards while coordinating approvals, deployments, and post-release communications with key stakeholders.
• Communicate product status, delivery metrics, risks, and key decisions clearly to leadership and governance forums.
• Own end‑to‑end product quality, documentation, and enablement, ensuring solutions align with enterprise standards, clinical workflows, and integration best practices.
• Define and track delivery and performance metrics and use data and feedback to drive continuous improvement.
• Other duties as assigned.

Clinical Systems Product Manager

• Lead and manage the daily operation of the department, 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 visits may occur for staff onboarding, facility support, or leadership meetings in the Seattle office.

Provider Network Analyst

Performance and Network Compliance Analyst

Case Manager, Diabetes Care Program – RN Preferred

Case Manager I, MSW/RN

Clinical Systems Product Manager

Manager, Clinical Utilization Management – Transitions of Care