Remote Clinical Specialist, Utilization Management

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

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.