Clinical Nurse Specialist (Nurse Informaticist) (CNS/CQCT)

State of Washington•Thurston County – Olympia, WA

4d•Remote

About The Position

This is a full-time permanent, remote position. Employees may occasionally be asked to attend an in-person meeting or event based on business needs. All HCA employees are required to be Washington state residents upon their first day of employment. The Clinical Quality and Care Transformation (CQCT) division is seeking a Clinical Nurse Specialist with nurse informatics expertise to lead HCA's implementation of state and federal prior authorization interoperability requirements, including HB 1357 (as amended by HB 1706) and CMS-0057-F. You will apply your clinical judgment and informatics knowledge to design and refine the systems, workflows, and policies that make prior authorization decisions more efficient, while ensuring Apple Health clients receive medically necessary, high-quality care.

Requirements

An active, unrestricted Washington State Registered Nurse license or Multi-State License.
Interoperability & Health Information Technology (HIT) API & Data Standards Expertise: Deep technical understanding of Application Programming Interfaces (APIs), HL7, and Fast Healthcare Interoperability Resources (FHIR) standards, specifically as they apply to patient access, provider directories, and prior authorization.
Electronic Health Record (EHR) Integration: Demonstrated ability to align complex provider EHRs and practice management systems with state payer databases.
Workflow Automation: Demonstrated ability to design and implement standard, nonproprietary open workflows that automate data collection and reduce administrative burdens for clinicians.
Regulatory Compliance & Policy Leadership Legislative Interpretation: Demonstrated mastery in interpreting and operationalizing federal Centers for Medicare & Medicaid Services (CMS) rulemaking and state regulations, specifically Washington Administrative Codes (WACs).
Policy Formulation: Demonstrated ability to advise executive leadership, Medical Directors, and/or division heads on the financial and clinical utilization impacts of new or modified health care regulations.
Advanced Utilization Review & Clinical Evaluation Evidence-Based Medical Necessity: Demonstrated competency in independently evaluating complex medical records against scientific evidence to make highly defensible prior authorization and claim payment determinations.
Administrative Hearing Defense: Demonstrated skills in preparing organizational position statements, drafting legal declarations, and delivering expert clinical testimony during formal appeals and utilization review denial hearings.
System Leadership & Change Management Cross-Functional Liaison: Demonstrated ability to serve as a high-level intermediary bridging the technical and clinical communication gaps between agencies, commercial payers, and community health care providers.
Contract & Resource Management Contract Monitoring: Demonstrated ability to successfully negotiate, structure, and monitor health care and technology vendor contracts to ensure agency alignment.
Clinical Education & Mentorship Subject Matter Expertise: Demonstrated ability to serve as the definitive, accessible clinical resource for all internal and external inquiries regarding assigned Medicaid clinical programs.
Equity lens – All HCA employees are required to consider equity in their decisions, processes, and day-to-day work, including how their work may affect the people and communities we serve.
The ability to take action to learn and grow – You take action to learn and grow by seeking new perspectives, learning from experiences, and using what you’ve learned to continuously improve how you work and serve others.
The ability to take action to meet the needs of others – You take action to meet the needs of others by listening, understanding different perspectives, and responding with care, respect, and solutions that support the people of the communities we serve.

Nice To Haves

National Coding Systems: Demonstrated proficiency in translating annual and quarterly CPT and HCPCS codes into active Medicaid policies, provider guides, and billing systems.
Continuous Quality Improvement (CQI): Demonstrated mastery in reviewing prior authorization and API metrics data to identify systemic gaps, generate federal reports, and lead intra-agency care delivery updates.
Alternative Care Negotiation : Demonstrated ability to consult with community providers to propose and negotiate alternative, covered, and more cost-effective treatment pathways that still meet the patient's clinical needs.
A master's degree in nursing (MSN or MN), business administration (MBA), or health administration (MHA).
Certification in informatics (RN-BC in Informatics or CPHIMS).
Knowledge of HCA structure, systems, communication methods, and forms.

Responsibilities

Lead oversight and implementation of the information exchange components of state and federal legislation regarding prior authorization and Application Programming Interface (API) for HCA and Medicaid.
Coordinate with HCA divisions, payers, and provider electronic health record (EHR) and practice management systems to identify prior authorization documentation requirements and support standard, automated data exchange using nonproprietary open workflows.
Guide the configuration of new and existing Medicaid clinical policies into payment systems and serve as HCA's subject matter expert on prior authorization, provider directory, patient access, and other interoperability initiatives.
Represent the Washington State Medicaid perspective in CMS rulemaking and in forums such as the Workgroup for Electronic Data Interchange (WEDI).
Conduct utilization reviews and make prior authorization and claim payment determinations using evidence-based clinical policy and the requirements of WAC 182-501-0165.
Review reconsideration requests, prepare the agency's position for administrative hearings, and provide declarations or testimony as needed.
Apply annual and quarterly CPT and HCPCS code updates to clinical policies, provider guides, and provider notices.
Analyze prior authorization and API metrics for state and federal reporting and advise leadership on new or modified policy and regulations, including cost and utilization impacts.
Negotiate and monitor contracts, support bill analysis and decision packages, and serve as a liaison with DSHS, the Department of Health, the Department of Corrections, and provider groups.