Manager Utilization Management

Cambia Health Solutions; Fargo (ND); Hybrid; USD 101,000 - 137,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401(k) with company match

Paid time off

Job summary

Cambia Health Solutions seeks a Manager of Utilization Management for a hybrid role, requiring leadership in clinical care and a strong background in insurance processes. This role guides staff across multiple offices in a collaborative environment and supports ongoing program improvements to ensure quality outcomes.

Ideal candidates hold an RN license, a nursing-related degree, and several years of leadership and insurance experience, with a preference for a master's degree.

Qualifications

• Bachelor's degree in nursing or related field; masters preferred.
• 5 years of clinical care experience.
• 5 years of leadership experience.
• 7 years of insurance industry experience or equivalent.
• Current unrestricted RN licensure in US

Responsibilities

• Leads development and execution of utilization management policies and standards.
• Oversees policy updates and process improvements for quality and service excellence.
• Manages staff performance reviews, coaching, and retention.
• Develops supervisors and participates in talent management activities.
• Monitors departmental goals and regulatory compliance.
• Allocates budget and resources and oversees project plans.

Skills

Leadership experience

Clinical care

Communication skills

Team building

Health insurance knowledge

Education

Bachelor's degree in nursing or related field

Master's degree preferred

RN licensure

Job description

Manager Utilization Management Hybrid role (3 days/week in office) at our Salt Lake City, Boise, Fargo, Portland, Vancouver, Renton, Medford, Burlington, Lewiston, Little Rock and Springdale offices. Preference will be given to current employees and candidates who reside within a commutable distance from our Salt Lake City, Boise, Fargo, Lewiston, Little Rock and Springdale offices or who are willing to relocate. 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 leaders are living our mission to make health care easier and lives better. As a member of the Utilization Management leadership team, our Manager Utilization Management Plans, directs, and manages the activities of the utilization management professional and support staff. Oversees staff directly or through subordinate supervisor(s). Provides leadership to set performance standards and ensure effective and efficient execution of utilization management programs across all Cambia plans, including prospective, concurrent, retrospective review and/or post service claims review and bill audit procedures. Represents the department in interactions with all levels of management, vendor partners, clients, providers, government officials, and outside consultants – all in service of making our members’ health journeys easier. As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us. Do you want to lead a team where your decisions directly impact making health care easier for thousands of members every single day? Would you thrive in a leadership role where you collaborate across all organizational levels—from frontline staff to government officials—to drive meaningful change in health care? Then this role may be the perfect fit.

Qualifications:

• Bachelor's degree in nursing or related field, masters preferred
• 5 years of clinical care experience
• 5 years of leadership experience
• 7 years of insurance industry experience or equivalent combination of education and experience
• Current unrestricted Registered Nurse (RN) Licensure, in a state or territory of the United States

Skills and Attributes:

• Ability to identify issues, opportunities, and effective solutions and collaborate with other departments to improve processes and/or results.
• Demonstrated competency in resource and project management: budgeting, organizing work, providing leadership to staff, establishing measures for success, and managing to deliverables.
• Ability to develop and lead a team including: hiring, goal setting, coaching and development (including supervisors and/or employees who may be in multiple locations or work remotely).
• Ability to communicate effectively, verbally and in writing, including meeting facilitation and presentations with employer or provider groups.
• Familiarity with health insurance industry trends and technology.
• Demonstrated competency in clinical case management and utilization management practices.
• Experience with statistical analysis and their application in utilization management programs.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

What You Will Do at Cambia:

• Leads the development and execution of effective utilization and/or payment review management policies, procedures and standards.
• Oversees the implementation of policy updates or process improvements as needed to ensure quality and service excellence.
• Handles all management level responsibilities for staff, including performance reviews, employee development, hiring, coaching, counseling, and retention.
• Develops supervisors and participates in talent management activities.
• Regularly communicates organizational objectives and team goals.
• Monitors results and metrics to ensure deliverables are met and compliance with department and regulatory standards.
• Collaborates with other leaders and across departments to resolve issues.
• Manages financial targets and department budget, authorizes expenditures, monitors workforce allocation and resources, and oversees project plans.
• In conjunction with division leadership, establishes long-term goals for department and adapts operational plans as changes occur.
• Creates visibility and support for utilization management and/or payment review programs.
• Develops resource materials and provides education and communication about programs to employees, providers and community stakeholders.
• Maintains clinical competency and keeps current on medical practices, procedures and industry trends.
• May develop and present educational updates to other departments.
• Oversees development and implementation of department programs.
• Responsible for program quality and successful outcomes of programs.
• As a member of our strong leadership community, you will provide direction to your team, engage them towards common goals and create a positive experience that helps people flourish.

FTEs Supervised 10-15 #LI-Hybrid

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 the Boise and Lewiston, ID; Salt Lake City, UT, Oregon and Washington. The full salary range is $105,000 - $172,000 and the bonus target is 17%. The expected salary range is $112,200 - $151,800.

Regional pay structure — applies to North Dakota and Idaho and Utah locations outside the metro areas listed above: The full salary range is $95,000 - $155,000 and the bonus target is 17%. The expected salary range is $101,000 - $136.600.

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?

At Cambia, you can: 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. 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.

Through our regional health insurance plans, innovative technologies and strategic investments, we are delivering consumer-centric solutions that:

• Help people achieve better health and well-being
• Make healthcare more available, affordable, and personalized
• Are easily understood by everyone

We put people at the heart of everything we do.

Our company reaches more than 70 million Americans nationwide, including more than 6 million people enrolled in our regional health plans. Cambia blends data science with a compassionate human perspective to anticipate people’s needs, and empower them to make smarter health care choices.