Manager, Clinical Utilization Management – Transitions of Care

Community Health Plan of Washington

Manager leading Utilization Management and Transitions of Care at Community Health Plan of Washington. Overseeing inpatient medical necessity reviews and team performance for improved member outcomes.

Posted 4/29/2026full-timeRemote • Washington • 🇺🇸 United StatesMid-LevelSenior💰 $101,740 - $163,800 per yearWebsite

About the role

Key responsibilities & impact

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.

Requirements

What you’ll need

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 three (3) years leading teams required, experience working with remote workers desired OR a minimum of three (3) years in a supervisory or management role required
Have a minimum of three (3) years acute or ambulatory 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.

Benefits

Comp & perks

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.

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills & Tools

utilization managementcare managementclinical qualityperformance targetsprocess improvementdischarge planningmember engagementregulatory requirementsacute clinical experienceambulatory clinical experience

Soft Skills

leadershipcoachingcollaborationstaff developmentcommunicationorganizational skillsproblem-solvingperformance monitoringteam managementadaptability

Certifications

RN licensebachelor's degree in nursingadvanced clinical degree