Hca Utilization Review Jobs (NOW HIRING)

Description Medical Supplies Nurse Program Manager (ONC/CQCT) 71114289 The Medical Supplies Nurse Program Manager (Occupational Nurse Consultant) uses their clinical expertise to shape health care policy for Washington's Medicaid population. This position manages clinical programs related to medical equipment, supplies, prosthetics, and orthotics while providing compliance and applying utilization review principles across large projects. This telework-eligible position is required to have an active, unrestricted Washington State Registered Nurse license or Multi-State License.

All HCA employees will apply an equity lens to their work, which may include but is not limited to all analyses of core business and processes. About the division: The mission of the Clinical Quality and Care Transformation (CQCT) within the HCA is to provide high quality health care through innovative health policies and purchasing strategies which assist in the purchase and delivery of health care services to qualified Washington citizens. CQCT staff work across the agency and between agencies (Department of Health, Department of Social and Health Services, etc.) and in partnership with health care providers and community stakeholders to develop, implement and manage high-quality, evidence-based health care programs that enhance clients' ability to access appropriate, quality health care

About the position: This Occupational Nurse Consultant (ONC) position reports directly to the Unit Supervisor in the Health Care Services unit of the CQCT division. This position is responsible for clinical programs and policies that pertain to medical equipment, supplies and prosthetics and orthotics. This position effectively manages clinical programs, including implementing policies and applying best practice principles in utilization management and quality of care standards that contribute to over $2 billion in federal and state Medicaid Title XIX, Titles XXI and state funds.

In addition, this position applies utilization review principles, as well as evidence-based WAC criteria, the principles of WAC 182-501-0165, and makes evidence-based medical necessity determinations for client specific medical services which require prior authorization. This position is eligible to telework and is typically not required to report on-site.The default assigned work location of all Health Care Authority (HCA) positions - both on-site and telework eligible positions - is within the State of Washington. This position reports to Olympia, WA

Frequency of onsite work will vary based on business and operational needs. All agency employees are required to report on-site in Olympia on their first and last days of employment to pick up and return state-issued equipment, regardless of telework status or location. Duties Some of what you will do: Serve as clinical program manager for assigned programs, implementing program goals and objectives, developing and implementing policy and procedures, clinical criteria, WAC, billing instructions and other relevant utilization management and quality assurance activities.

Serve as clinical resource and subject matter expert to both internal and external stakeholders for all clinical issues/questions related to assigned programs. Responsible for interpretation of applicable WACs and assures adherence to department rules and policy. Review and evaluate available scientific evidence to apply evidence based clinical policy when making utilization review determinations and health care benefit coverage decisions.

Make independent clinical decisions about the adequacy, appropriateness, and conformance with accepted standards of care, of services proposed by physicians and practitioner assistants to make an authorization determination. Present clinical review findings, orally and in writing, to medical consultants as needed to establish medical necessity of care and reach an authorization determination. Prepare the authorization determination including reason for denial, alternatives of care and other information consistent with the requirements of WAC and policy.

Review records submitted for consideration in hearings. Work with staff to identify opportunities for education of HCA staff and community healthcare professionals to support program success. Conduct analysis of clinical data evaluating success of program and progress towards program objectives, prepare reports of analysis, including recommendations for program modifications or discontinuation, if indicated.

Determine application of the yearly and quarterly national CPT and HCPCs codes including updating relevant policies and provider communications including provider notices and provider guide. Represent Medicaid in inter and intra agency initiatives, including continuous quality improvement initiatives, revisions to delivery of care models, litigation negotiations, Advises manager, Medical Director, division directors and executive leadership of need for new regulations, formulating policy, or modifying existing policy/regulation using data to support position, including cost and utilization implications. Make referrals to other department units and divisions or other state agencies, including Quality Management Team, Medical/Hospital Audit or Department of Health, as indicated.

Negotiate and monitor contracts. Qualifications Required qualifications: Qualifying candidates will meet one of the following criteria options: All options are required to have an active, unrestricted Washington State Registered Nurse license or Multi-State License. Option 1: Master's degree in Nursing, and two (2) years of clinical or functional nursing experience.

Option 2: Bachelor's degree in Nursing, and two (2) years of clinical or functional nursing experience and two (2) years of related administrative, consultative, or case management experience. Option 3: Three (3) years of clinical or functional nursing experience and two (2) years of related administrative, consultative, or case management experience. Required competencies: The ability to take action to learn and grow.

The ability to take action to meet the needs of others. Preferred qualifications: Bachelor of Science Degree in Nursing or Bachelor's in closely allied field Experience writing Medicaid State Plan Amendments, Washington Administrative Code, Medicaid Provider Guides, and technical reports. Provider One experience Background in systems theory and health services reform, including working collaboratively with multiple stakeholders to determine changes needed to effect reform.

Demonstrated knowledge: Knowledge of state and federal laws, policies, regulations and procedures that apply to Medicaid and healthcare delivery. Knowledge and understanding of medical equipment and supplies. Knowledge and skills in researching evidence basis for performance measures and quality improvement interventions.

Knowledge and experience in working with diverse client populations. Knowledge of cultural competency and equity principles as they relate to program development, implementation, management and quality oversight. Knowledge of coding principles/rules for ICD-10.

Demonstrated skills: Excellent verbal and written communication skills, including technical and non-technical report writing and oral presentations with a wide variety of audiences including the legislature, managed care organizations, providers, and other state agency staff. Strong leadership, communication and program management skills; including the ability to work across boundaries, work both independently and collaboratively, and meet deadlines. Facilitating meetings with state and external participants.

Computer software literacy. Public relations and customer service skills, including conflict resolution and negotiating techniques. Demonstrated ability to: Manage multiple activities, establish priorities, and advance assigned projects from inception to completion with limited supervision.

Communicate about clinical principles and interventions in clear, understandable language for audiences of varying backgrounds and knowledge levels. Maintain effective relationships with multi-disciplines and agencies involved in Medicaid programs. Independently manage competing timelines to meet critical deadlines and manage multiple projects concurrently.

Plan strategically and perform research. Interpret data and provide written analysis to understand the data. Demonstrated behaviors: Adhere to the core values of HCA: honest, forthright, and respectful discourse among equals; timely, active and meaningful engagement/performance of work.

Maintain the highest standards of personal/professional and ethical conduct. Model behaviors that encourage an open, inclusive work environment. Work schedule flexibility.

How to apply: Only candidates who reflect the minimum qualifications on their NEOGOV profile will be considered. Failure to follow the application instructions below may lead to disqualification. To apply for this position, you will need to complete your profile which includes three professional references and attach in separate files: A cover letter that specifically addresses how you meet the qualifications for this position Current resume To take advantage of veteran preference, please do the following: Attach a copy of your DD214 (Member 4 long-form copy), NGB 22, or USDVA signed verification of service letter.

Please black out any PII (personally identifiable information) data such as social security numbers. Include your name as it appears on your application in careers.wa.gov. Supplemental Information About HCA: Functioning as both the state's largest health care purchaser and its behavioral health authority, the Washington State Health Care Authority (HCA) is a leader in ensuring Washington residents have the opportunity to be as healthy as possible

There are three pillars of our work: Apple Health (Medicaid); the Public Employees Benefits Board (PEBB) and School Employees Benefits Board (SEBB) programs; and behavioral health and recovery. Under these pillars, HCA purchases health care, including behavioral health treatment for more than 2.7 million Washington residents and provides behavioral health prevention, crisis, and recovery supports to all Washington residents. What we have to offer: Meaningful work with friendly co-workers who care about those we serve Voices of HCA A clear agency mission that drives our work and is person-centered HCA's Mission, Vision & Values A healthy work/life balance, including alternative/flexible schedules and mobile work options

A great total compensation and benefit package WA State Government Benefits A safe, pleasant workplace in a convenient location with restaurants, and shopping nearby. And free parking. Notes: Please note, salary is based on experience and is determined at the time a final offer of employment is made.

Per State HR guidance, nursing salaries are considered a "special pay range" and details on that range can be found here: N Range details. The salary range listed in the job posting includes steps A-U. Step U is a longevity step and is typically gained six years into being assigned step T in your permanent salary range.

Prior to a new hire, a background check including criminal record history will be conducted. Information from the background check will not necessarily preclude employment. HCA is an equal opportunity employer.

We value the importance of creating an environment in which all employees can feel respected, included, and empowered to bring unique ideas to the agency. HCA has five employee resource groups (ERGs). ERGs are voluntary, employee-led groups whose aim is to foster a diverse, inclusive workplace aligned with HCA's mission.

Our diversity and inclusion efforts include embracing different cultures, backgrounds and viewpoints while fostering growth and advancement in the workplace. Studies have shown women, racial and ethnic minorities, and persons of disability are less likely to apply for jobs unless they feel they meet every qualification as described in a job description. Persons over 40 years of age, disabled and Vietnam era veterans, as well as people of all sexual orientations and gender identities are also encouraged to apply.

If you have any questions about the required qualifications or how your experience relates to them, please contact us at HCAjobs@hca.wa.gov.Persons with disabilities needing assistance in the application process, or those needing this job announcement in an alternative format may contact Lisa Fleming at (360) 725-1723 or lisa.fleming@hca.wa.gov 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

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