Clinical Specialist (nonclinical)

Cambia Health Solutions; Idaho; Remote; USD 33,000 - 54,000; Full time

Benefits offered by this job

Medical, dental, vision coverage

Health savings account

Paid time off and holidays

Retirement plan with company match

Parental leave

Job summary

Cambia Health Solutions seeks a Clinical Specialist to support utilization management and regulatory compliance from a remote home base across Idaho, Oregon, Utah, and Washington. The role emphasizes clinical insight, documentation, and collaboration with RNs to optimize member care.

Responsibilities include reviewing requests, gathering information, performing nonclinical tasks, and communicating with providers.

Qualifications

• High school diploma or equivalent with 2 years of clinical or hospital experience; LPN, CMA or CNA preferred.
• Experience with EMR, billing, and claims systems.
• Strong organizational and data management abilities.

Responsibilities

• Research simple to moderately complex UM requests using clinical knowledge.
• Review requests for completeness and prepare cases for clinical review.
• Complete nonclinical case tasks and document critical information.
• Outreach to providers by phone and email to obtain records and communicate determinations.
• Meet standards for timeliness, production, quality, and accuracy per regulatory requirements.
• Collaborate across teams and maintain organized reference materials; uphold a professional, member-focused environment.
• Assist with workflow improvements and system testing when needed.

Skills

Clinical experience

Communication skills

EMR systems

Medical terminology

Data entry

Organizational skills

Independent worker

Team collaboration

AI tools experience

Education

High school diploma or equivalent

Job description

Clinical Specialist

Work from home within Idaho, Oregon, Utah, and Washington. Preference will be given to current employees and candidates who reside in Idaho, or Utah.

Build a Career with Purpose. Join our Cause

to create a person-focused and economically sustainable health care system.

Who We Are Looking For

Every day, Cambia’s dedicated team of Clinical Specialist is living our mission to make health care easier and lives better. As a member of the Clinical Operations team, our Clinical Specialists help us meet regulatory requirements as we insource prior authorization volume, support key initiatives, and ensure strong staffing coverage. By handling nonclinical tasks, they free up RNs to focus on clinical work and increase overall capacity – all in service of making our members’ health journeys easier.

Do you have strong organization and data management skills? Do you work effectively in a team environment? Then this role may be the perfect fit.

Qualifications

What You Bring to Cambia:

• Clinical Specialist would have a high school diploma or equivalent and 2 years of clinical or hospital experience, or an equivalent combination of education and experience. LPN, CMA or CNA preferred.

Skills And Attributes

• Clinical experience, preferably in a hospital setting or a health plan clinical services setting.
• Strong and effective communication skills, both oral and written.
• Ability to work in a fast-paced environment while maintaining accuracy of work, confidentiality, and focus on meeting customer needs.
• Intermediate computer skills (e.g. Microsoft Office, Outlook, Internet search) and experience with health care systems and documentation (EMR, billing and claims).
• Demonstrated knowledge of medical terminology, anatomy and coding (CPT, DX, HCPCs).
• Strong organization, data entry, and administrative skills.
• Ability to investigate and research complex issues and inquiries related to UM case work, use critical thinking skills and work with clinical staff to resolve them.
• Ability to work independently, to prioritize work, meet deadlines and achieve operational standards.
• Ability to work effectively in a team environment.
• Ability to perform job duties and responsibilities for an UM Clinical Specialist.
• Ability to mentor and support co-workers and provide training to new team members
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

What You Will Do At Cambia

• Uses clinical knowledge and critical thinking to research simple to moderately complex requests and documentation related to utilization management (UM) processes and regulatory requirements.
• Reviews requests for completeness, obtains any missing information, and prepares cases for clinical review.
• Completes nonclinical case tasks, including documenting critical information, initiating referrals, and closing cases accurately.
• Conducts telephonic and written outreach to providers to request medical records and communicate case determinations, cancellations, and other information in compliance with regulatory and quality requirements.
• Manages time effectively and follows established guidelines to meet departmental standards for timeliness, production, quality, and accuracy, as well as federal, state, BCBSA, and accreditation requirements.
• Communicates effectively within and across teams, maintains organized access to reference materials, policies, and procedures, and upholds a professional, ethical, member-focused work environment.
• Supports continuous improvement by identifying workflow and system opportunities, and may assist with systems testing, coordinate case information in external vendor systems, or discuss service planning with providers.

Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.

• National pay structure — applies to Washington, Oregon, and to the Boise, Lewiston, and Salt Lake City metro areas: The full hourly range is $26.50 - $43.20 per hour and the bonus target is 5%.
• Regional pay structure — applies to Idaho, and Utah locations outside the metro areas listed above: The full hourly range is $23.90 - $38.90 per hour and the bonus target is 5%.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

• Work alongside diverse teams building cutting-edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

Benefits

In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.

As part of our security requirements, new hires will need access to a personal mobile device to set up Multi-Factor Authentication (MFA) upon joining the company. MFA is an important layer of protection for accessing Cambia systems and is required for all employees.

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email [e-mail]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.