Remote Utilization Management Nurse

Cambia Health Solutions; Portland (OR); Remote; USD 77,000 - 105,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Health savings account (HSA)

Generous paid time off

Retirement plan with company match

Parental leave

Job summary

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to support clinical reviews and care coordination across Oregon, Washington, Idaho, and Utah. This role emphasizes medical necessity determinations and collaboration with physician advisors to ensure quality and cost-effective outcomes.

Ideal candidates hold an RN license and have 3+ years in case management or utilization management while possessing strong communication and documentation skills.

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 health or human services discipline with at least 3 years of direct clinical care
• May need licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington
• RN license (current unrestricted) or equivalent credential

Responsibilities

• Conduct utilization management reviews (prospective, concurrent, retrospective) to ensure medical necessity and policy compliance
• Apply clinical expertise and evidence-based criteria to make determinations and consult with physician advisors as needed
• Collaborate with interdisciplinary teams, case management, and other departments to facilitate transitions of care
• Serve as a resource to internal and external customers with accurate and timely responses
• Identify opportunities for improvement and participate in quality improvement efforts
• Maintain accurate and consistent documentation and prioritize assignments to meet performance standards

Skills

Case management

Utilization management

Nursing licensure

Interdisciplinary collaboration

Communication skills

MS Office / Outlook

AI tools experience

Education

Associate or Bachelor’s Degree in Nursing or related field

RN license (current unrestricted)

Tools

Health care documentation systems

Microsoft Office / Outlook

Job description

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to support clinical reviews and care coordination across Oregon, Washington, Idaho, and Utah. This role emphasizes medical necessity determinations and collaboration with physician advisors to ensure quality and cost-effective outcomes.

Ideal candidates hold an RN license and have 3+ years in case management or utilization management while possessing strong communication and documentation skills.