Remote Utilization Management Nurse

Cambia Health Solutions, Inc.; Salem (OR); Remote; USD 51,000 - 69,000; Full time

Benefits offered by this job

Health benefits

Bonus opportunities

Retirement plan

Job summary

Cambia Health Solutions, Inc. is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews for member care across multiple states.

The role emphasizes applying clinical criteria, ensuring medical necessity, and coordinating with care teams. Ideal candidates hold an RN license with 3+ years in case or utilization management, and can work from home within Oregon, Washington, Idaho or Utah.

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 U.S. state/territory and at least 3 years of direct clinical care.

Responsibilities

• Conducts utilization management reviews to ensure medical necessity and compliance with policy and standards of care.
• 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 timely responses to inquiries.
• Identifies opportunities for improvement and participates in quality improvement efforts.
• Maintains accurate documentation and prioritizes assignments to meet performance standards.

Job description

Cambia Health Solutions, Inc. is seeking an Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews for member care across multiple states.

The role emphasizes applying clinical criteria, ensuring medical necessity, and coordinating with care teams. Ideal candidates hold an RN license with 3+ years in case or utilization management, and can work from home within Oregon, Washington, Idaho or Utah.