Remote Utilization Management Nurse

Cambia Health; Spokane (WA); Remote; USD 48,000 - 79,000; Full time

Benefits offered by this job

Competitive salary

Market-leading benefits

401(k) with company match

Generous PTO and holidays

Job summary

Cambia Health is seeking an Utilization Management Nurse to work remotely within Oregon, Washington, Idaho or Utah. The role focuses on prospective, concurrent and retrospective reviews to ensure medical necessity and cost-effective care, applying expert clinical judgment and evidence-based criteria.

Ideal candidates hold an RN license with 3+ years in case management or utilization management and may require licensure in multiple states Cambia serves.

Qualifications

• Three years of case management, utilization management, disease management, auditing or retrospective review experience.
• Must have licensure or certification in a state or territory of the United States that allows independent assessment.
• May need licensure in all four states Cambia serves: Idaho, Oregon, Utah, Washington.
• Bachelor's or higher degree in a health or human services-related field or RN license with current unrestricted RN license for Medical Care Management.

Responsibilities

• Conducts utilization management reviews (prospective, concurrent, and retrospective) 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, case management, and other departments 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 and consistent documentation and prioritizes assignments to meet performance standards and corporate goals.
• Protects confidentiality of sensitive documents and issues while communicating professionally with members, providers, and regulatory organizations.

Skills

Case management experience

Utilization management

Interdisciplinary collaboration

Communication skills

Independent decision making

Education

Associate or Bachelor's Degree in Nursing

Job description

Cambia Health is seeking an Utilization Management Nurse to work remotely within Oregon, Washington, Idaho or Utah. The role focuses on prospective, concurrent and retrospective reviews to ensure medical necessity and cost-effective care, applying expert clinical judgment and evidence-based criteria.

Ideal candidates hold an RN license with 3+ years in case management or utilization management and may require licensure in multiple states Cambia serves.