[Hiring] Occupational Nurse Consultant @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 Nurse Informaticist 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.
• Support information gathering and coordination as needed for HCA/Medicaid to identify prior authorization information and documentation requirements and facilitate exchange of prior authorization requests and determinations between provider electronic health record (EHR)/practice management systems and relevant payers.
• Support development of standard and automated approaches using nonproprietary open workflows to compile and exchange the necessary data elements to populate prior authorization requirements.
• Engage CQCT team members, project team members, and applicable divisions to understand current state of prior authorization workflows; provide guidance for configuration of new and existing Medicaid clinical policies into payment systems.
• Coordinate informatics resources and clinical information system initiatives related to HCA divisions and external EHR systems.
• Facilitate and optimize informatics processes, enhance coordination, training, support processes and provide overall direction for clinical informatics requiring the use of leadership and decision-making abilities.
• Facilitate processes that improve efficiency, reduce team/clinician burden, and enhance patient care.
• Serve as a liaison between HCA, providers, payers, and the community regarding clinical information system initiatives.
• Participate in forums such as the Workgroup for Electronic Data Interchange (WEDI).
• Serve as a subject matter expert for matters related to prior authorization interoperability and other interoperability initiatives including but not limited to provider directory, patient access, and other APIs, and integration into current and new HCA initiatives.
• Provide WA state Medicaid agency perspective in CMS rulemaking.
• Collaborate with HCA management and staff in the formulation of statewide policy and clinical standards that ensure the delivery of quality care is rendered and services are appropriately utilized.
• Work with staff to identify opportunities for education of HCA staff and community health care professionals to support program success.
• 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.
• 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.
• Participate in required state or federal reporting for prior authorization or API metrics. Review and evaluate data related to prior authorization, supporting needed reports and any next steps.
• Represent Medicaid in inter and intra agency initiatives, including continuous quality improvement initiatives, revisions to delivery of care models, litigation negotiations.

Qualifications

• An active, unrestricted Washington State Registered Nurse license or Multi-State License.
• 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.
• 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 and reduce administrative burdens for clinicians.
• Demonstrated mastery in interpreting and operationalizing federal Centers for Medicare & Medicaid Services (CMS) rulemaking and state regulations, specifically Washington Administrative Codes (WACs).
• 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.
• Demonstrated competency in independently evaluating complex medical records against scientific evidence to make highly defensible prior authorization and claim payment determinations.
• Demonstrated skills in preparing organizational position statements, drafting legal declarations, and delivering expert clinical testimony during formal appeals and utilization review denial hearings.
• 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.
• Demonstrated ability to successfully negotiate, structure, and monitor health care and technology vendor contracts to ensure agency alignment.
• Demonstrated ability to serve as the definitive, accessible clinical resource for all internal and external inquiries regarding assigned Medicaid clinical programs.

Requirements

• 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.

Preferred Qualifications

• Demonstrated proficiency in translating annual and quarterly CPT and HCPCS codes into active Medicaid policies, provider guides, and billing systems.
• Demonstrated mastery in reviewing prior authorization and API metrics data to identify systemic gaps, generate federal reports, and lead intra-agency care delivery updates.
• 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.

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