Remote Clinical Specialist - Utilization & UM Support

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

Job summary

Cambia Health Solutions is seeking a Clinical Specialist to support utilization management from a home-based location across ID, OR, UT, and WA. This role helps ensure regulatory compliance, handles nonclinical tasks, and frees up RNs for clinical work.

The ideal candidate has a high school diploma with 2 years of clinical or hospital experience, strong communication, EMR skills, and knowledge of medical coding. Remote position with a national pay structure and growth opportunities.

Qualifications

• High school diploma or equivalent with 2 years clinical or hospital experience.
• LPN, CMA or CNA preferred.
• Experience with EMR, billing and claims.
• Knowledge of CPT, DX, HCPCS.
• Strong communication and organizational skills.

Responsibilities

• Research requests related to utilization management and regulatory requirements.
• Review requests for completeness and prepare cases for clinical review.
• Complete nonclinical case tasks including documentation, referrals and closing cases.
• Conduct telephonic and written outreach to providers to request records and communicate determinations.
• Manage time to meet department standards for timeliness, quality and accuracy.
• Communicate within and across teams and uphold professional, member-focused environment.
• Identify workflow/system opportunities and assist with system testing or service planning.

Skills

Clinical experience

Communication

Fast-paced environment

EMR experience

Medical terminology and coding

Organization and data entry

Investigate complex issues

Independent work

Team collaboration

Mentoring/training

AI tools experience

Education

High school diploma or equivalent

2 years clinical or hospital experience

Job description

Cambia Health Solutions is seeking a Clinical Specialist to support utilization management from a home-based location across ID, OR, UT, and WA. This role helps ensure regulatory compliance, handles nonclinical tasks, and frees up RNs for clinical work.

The ideal candidate has a high school diploma with 2 years of clinical or hospital experience, strong communication, EMR skills, and knowledge of medical coding. Remote position with a national pay structure and growth opportunities.