Remote Utilization Management Nurse

Cambia Health Solutions; Pocatello (ID); Remote; USD 77,000 - 105,000; Full time

Benefits offered by this job

Medical coverage

Dental coverage

Vision coverage

401(k) with company match

Paid holidays

Job summary

Cambia Health Solutions seeks an Utilization Management Nurse to conduct reviews (prospective, concurrent, retrospective) and ensure medical necessity and policy compliance. You will consult with physician advisors and collaborate with interdisciplinary teams to improve transitions of care and patient outcomes.

The role emphasizes applying evidence-based criteria, extensive documentation, and strong communication skills to support members, providers, and regulatory bodies.

Qualifications

• Associate or Bachelor’s Degree in Nursing or related field.
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Must have licensure or certification in a US state or territory allowing independent assessment.
• May need to have licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington.
• One of: Bachelor’s degree in health or human services-related field; or RN license.

Responsibilities

• Conducts utilization management reviews to ensure medical necessity and compliance with policy.
• Applies clinical expertise and evidence-based criteria to make determinations.
• Collaborates with interdisciplinary teams to facilitate transitions of care.
• Serves as a resource to internal and external customers with accurate responses.
• Identifies opportunities for improvement and participates in quality improvement.

Skills

Health insurance knowledge

MS Office

Communication skills

Policy interpretation

Time management

AI tools experience

Education

Associate or Bachelor’s Degree in Nursing

RN license

Tools

Microsoft Office

Documentation systems

Job description

Cambia Health Solutions seeks an Utilization Management Nurse to conduct reviews (prospective, concurrent, retrospective) and ensure medical necessity and policy compliance. You will consult with physician advisors and collaborate with interdisciplinary teams to improve transitions of care and patient outcomes.

The role emphasizes applying evidence-based criteria, extensive documentation, and strong communication skills to support members, providers, and regulatory bodies.