Clinical Nurse Specialist; Nurse Informaticist); CNS​/CQCT

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.

• 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 rule making 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 .
• 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.

• 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.

You are a curious, systems-minded nurse who is as comfortable reviewing a complex medical record as you are talking through data standards with a technical team. You make sound, independent clinical decisions and explain your reasoning clearly, whether in a provider letter, a leadership briefing, or a hearing. You build bridges between clinicians, technologists, and policy staff, translating each group's needs so the work can move forward.

You stay current on emerging regulations and technology and enjoy sharing what you know with others.

Experience may have been gained through paid or unpaid activities. Please ensure any relevant experience defined below is outlined in your cover letter, resume, and application.

• 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…