Remote Clinical Specialist – Utilization Management (UM)

Cambia Health Solutions; Washington; Remote; USD 37,000 - 60,000; Full time

Benefits offered by this job

Flexible work from home

Competitive benefits

401(k) with company match

Paid time off

12 weeks parental leave

Wellness programs

Employee assistance

Job summary

Cambia Health Solutions is seeking a Clinical Specialist to support utilization management processes from a home-based model across select western states. You will review requests, gather information, and prepare cases for clinical review while coordinating with providers to obtain records and communicate determinations.

The role emphasizes regulatory compliance, accurate documentation, and collaboration with RN staff to optimize staffing and patient care.

Qualifications

• High school diploma or equivalent required with 2 years of clinical or hospital experience, LPN/CMA/CNA preferred.
• Clinical experience in hospital or health plan settings preferred.
• Experience with EMR, billing and claims systems; strong communication and organization skills.

Responsibilities

• Research simple to moderately complex UM requests using clinical knowledge and regulatory requirements.
• Review requests for completeness and obtain missing information to prepare cases for clinical review.
• Complete nonclinical case tasks, document critical information, initiate referrals, and close cases accurately.
• Contact providers by phone or email to request medical records and communicate case determinations in compliance with regulations.
• Manage time to meet departmental timeliness, production, quality, and accuracy standards; follow policies and procedures.
• Communicate across teams, maintain access to reference materials, and uphold professional, ethical service.
• Support workflow improvements and coordinate case information in external vendor systems or with providers.

Skills

Clinical experience

Communication skills

Microsoft Office

EMR systems

Billing systems

Medical terminology

Data entry

Team collaboration

Mentoring

AI tools

Education

High school diploma or equivalent

LPN / CMA / CNA preferred

Tools

Outlook

Job description

Cambia Health Solutions is seeking a Clinical Specialist to support utilization management processes from a home-based model across select western states. You will review requests, gather information, and prepare cases for clinical review while coordinating with providers to obtain records and communicate determinations.

The role emphasizes regulatory compliance, accurate documentation, and collaboration with RN staff to optimize staffing and patient care.