[Hiring] Clinical Nurse Specialist @State of Washington

Role Description

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.

Help shape how Washington Medicaid connects clinical care and technology. 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.

Key Responsibilities Include:

• 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.

Why You’ll Love This Role:

• Your nursing expertise will have statewide reach, helping Apple Health clients get timely access to the care they need.
• You'll be at the forefront of health care interoperability, helping Washington put national data standards like FHIR into everyday practice.
• You'll reduce administrative burden on clinicians across the state, freeing more of their time for patient care.
• You'll work remotely with flexible scheduling options, as part of a clinical team that values innovation and evidence-based practice.

Qualifications

• An active, unrestricted Washington State Registered Nurse license or Multi-State License.
• Deep technical understanding of Application Programming Interfaces (APIs), HL7, and Fast Healthcare Interoperability Resources (FHIR) standards.
• Demonstrated ability to align complex provider EHRs and practice management systems with state payer databases.
• Demonstrated ability to design and implement standard, nonproprietary open workflows that automate data collection.
• Demonstrated mastery in interpreting and operationalizing federal CMS rulemaking and state regulations.
• Demonstrated ability to advise executive leadership on financial and clinical utilization impacts of new regulations.
• Demonstrated competency in independently evaluating complex medical records against scientific evidence.
• Demonstrated skills in preparing organizational position statements and delivering expert clinical testimony.
• Demonstrated ability to serve as a high-level intermediary bridging communication gaps between agencies and providers.
• Demonstrated ability to successfully negotiate, structure, and monitor health care and technology vendor contracts.
• Demonstrated ability to serve as the definitive clinical resource for Medicaid clinical programs.

Requirements

• Equity lens – All HCA employees are required to consider equity in their decisions and processes.
• The ability to take action to learn and grow by seeking new perspectives and learning from experiences.
• The ability to take action to meet the needs of others by listening and responding with care and respect.

Preferred Qualifications

• Demonstrated proficiency in translating annual and quarterly CPT and HCPCS codes into active Medicaid policies.
• Demonstrated mastery in reviewing prior authorization and API metrics data to identify systemic gaps.
• Demonstrated ability to consult with community providers to propose and negotiate alternative treatment pathways.
• 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.

Benefits

• Remote work and flexible schedules.
• Medical, dental, vision, and basic life insurance.
• Paid vacation, sick leave, and 12 paid holidays.
• Paid Family and Medical Leave (PMFL).
• Retirement options to plan for the future.
• Training and professional development opportunities.
• Employee wellness programs.