Remote Utilization Review Rn Jobs in Seattle, WA

This position is remote. We are targeting an individual who lives in the Seattle area and is knowledgeable of the area and its available resources. This is essential in being able to assist our Medicare and Dual Plan members by providing education coordination with care teams and connecting to community-based resources.

Who we are

Community Health Plan of Washington is an equal opportunity employer committed to a diverse and inclusive workforce. All qualified applicants will receive consideration for employment without regard to any actual or perceived protected characteristic or other unlawful consideration.

Our commitment is to:

• Strive to apply an equity lens to all our work.
• Reduce health disparities.
• Become an anti-racist organization
• Create an equitable work environment.

About the Role

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.

To be successful in this role, you:

• Have a Bachelor’s degree in nursing, or a master’s degree in social work and/or related behavior health field (preferred)
• Possess Current, unrestricted license in the State of Washington as a registered nurse (RN) (required) OR
• Current, unrestricted license in the State of Washington as a Social Worker (LSWAA, LSWAIC) (required), OR
• Current, unrestricted license in the State of Washington as a Mental Health Counselor (LMHC), Mental Health Professional (LMHP), or Marriage and Family Therapist (LMFT) (required)
• Have a minimum of one (1) year case management, home health or discharge planning experience; or a combination of education and experience which provides an equivalent background required OR
• Have a minimum of one (1) year facility-based medical or behavioral health experience and/or outpatient psychiatric and substance abuse/substance abuse disorder treatment experience, required; or equivalent combination of education and experience and/or working with children and families. Experience with those who have disabilities and knowledge of Child and Families Services
• Have a minimum three (3) years of clinical experience in an acute care and/or outpatient setting (required)
• Experience and proficiency with Microsoft Office products
• Possess a Case Management Certification (preferred)
• Have Bilingual abilities (preferred)

Essential functions and Roles and Responsibilities:

The Case Manager I is responsible for performing telephonic case management for members with acute, chronic, and complex needs. Examples listed below are not necessarily exhaustive and may be revised by the employer.

• 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. It is essential that a current driver’s license, proof of insurance and an acceptable driving record are maintained.
• 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. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.

Knowledge, Skills, and Abilities:

• Managed care (Medicaid and/or Medicare) experience
• Previous experience using Care Management software applications
• Knowledge of, and experience with, community resources preferred
• Knowledge of Medicare and Medicaid regulations
• Experience in care management workflow systems
• Effective verbal and written communication skills
• Effective organizational, time management, and project management skills
• Ability to work independently
• Comfortable presenting in a group setting
• Perform all functions of the job with accuracy, attention to detail and within established timeframes.
• Meet attendance and punctuality standards

Note: If you think you do not qualify, please reconsider. Studies have shown that women and people of color are less likely to apply to jobs unless they feel they meet every qualification. However, everyone brings different strengths to the table for a job, and people can be successful in a role in a variety of ways. If you are excited about this job but your experience doesn’t perfectly check every box in the job description, we encourage you to apply anyway.

As part of our hiring process, the following criteria must be met:

• Complete and successfully pass a criminal background check

Criminal History: includes review of criminal convictions and probation. CHPW does not automatically or categorically exclude persons with a criminal background from employment. The applicant’s criminal history will be reviewed on a case-by-case basis considering the risk to the business, members, and/employees.

• Has not been sanctioned or excluded from participation in federal or state healthcare programs by a federal or state law enforcement, regulatory, or licensing agency
• Vaccination requirement (CHPW offers a process for medical or religious exemptions)
• Candidates whose disabilities make them unable to meet these requirements are considered fully qualified if they can perform the essential functions of the job with reasonable accommodation.

Compensation and Benefits:

The position is FLSA Exempt and is not eligible for overtime and has a 10% annual incentive target based on company, department, and individual performance goals. The base pay actually offered will take into account internal equity and also may vary depending on the candidate’s job-related knowledge, skills, and experience among other factors.

CHPW offers the following benefits for Full and Part-time employees and their dependents:

• 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

Sensory/Physical/Mental Requirements:

Sensory*:

• Speaking, hearing, near vision, far vision, depth perception, peripheral vision, touch, smell, and balance.

Physical*:

• Extended periods of sitting, computer use, talking, and possibly standing
• Simple grasp, firm grasp, fine manipulation, pinch, finger dexterity, supination/pronation, wrist flexion

Mental:

• Must have the ability to learn and prioritize multiple tasks within the scope and guidelines of the position and its applicable licensure requirements, many requiring extremely complex cognitive capabilities. Must be able to manage conflict, communicate effectively and meet time-sensitive deadlines.

Work Environment:

Office environment Employees who frequently work in front of computer monitors are at risk for environmental exposure to low-grade radiation.