Manager, Clinical Utilization Management & Transitions of Care

Community Health Plan of Washington•Seattle, WA

18h•Hybrid

About The Position

This position leads and oversees the team focusing on utilization management inpatient medical necessity reviews and transitions of care (TOC) efforts, including post-discharge outreach and onsite facility engagement, to support safe, timely, and effective transitions across care settings. This leader partners closely with the broader Utilization Management team, network facilities, and vendors to develop and optimize workflows that ensure regulatory compliance, operational efficiency, and high-quality member outcomes. The role plays a key part in driving performance across clinical quality, timeliness, and care coordination while strengthening relationships with providers and improving the overall member experience.

Requirements

Hold a current, unrestricted RN license in the State of Washington.
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.
Complete and successfully pass a criminal background check.
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.

Nice To Haves

Have a bachelor’s degree in nursing or an advanced clinical degree, or additional advanced clinical training, preferred.
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.
Knowledge in criteria sets, including MCG preferred.

Responsibilities

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.
Other duties as assigned. Essential functions listed are not necessarily exhaustive and may be revised by the employer, at its sole discretion.