Remote Utilization Management Nurse

Cambia Health; Bend (OR); Teletrabalho; USD 48 000 - 79 000; Tempo integral

Resumo da oferta

Cambia Health is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews within a remote-capable role serving eligible states. You will apply evidence-based criteria to determine medical necessity, collaborate on care transitions, and support efficient, compliant pay decisions.

The position emphasizes independent clinical judgment, strong communication, and adherence to policy while supporting member health journeys and cost-effective outcomes.

Qualificações

• Associate or Bachelor’s Degree in Nursing or related field.
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Equivalent combination of education and experience.
• Must have licensure or certification in a U.S. state/territory allowing independent assessment and at least 3 years direct clinical care.
• May need licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington.
• Bachelor’s degree or higher in a health or human services-related field or RN license with current unrestricted status.

Responsabilidades

• Conducts utilization management reviews (prospective, concurrent, retrospective) to ensure medical necessity and policy compliance.
• Applies clinical expertise and evidence-based criteria to make determinations and consults with physician advisors as needed.
• Collaborates with interdisciplinary teams to facilitate transitions of care and resolve issues.
• Serves as a resource to internal and external customers, providing accurate and timely responses to inquiries.
• Identifies opportunities for improvement and participates in quality improvement efforts.
• Maintains accurate documentation and prioritizes assignments to meet performance standards.

Conhecimentos

Communication skills

Interpersonal skills

Time management

Critical thinking

Verbal/written communication

Formação académica

Associate or Bachelor’s Degree in Nursing or related field

RN licensure (current, unrestricted)

Licensure in Idaho, Oregon, Utah, and Washington (may be required)

Bachelor’s or higher in Health or Human Services-related field

Ferramentas

Microsoft Office

Outlook

Health care documentation systems

Descrição da oferta de emprego

Cambia Health is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews within a remote-capable role serving eligible states. You will apply evidence-based criteria to determine medical necessity, collaborate on care transitions, and support efficient, compliant pay decisions.

The position emphasizes independent clinical judgment, strong communication, and adherence to policy while supporting member health journeys and cost-effective outcomes.