Remote Utilization Management Nurse

Cambia Health Solutions, Inc.; Yakima (WA); Remote; USD 48,000 - 79,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Health savings account with employer +

Paid time off and holidays

Company 401(k) with match

Parental leave

Job summary

Cambia Health Solutions, Inc. is seeking an experienced Utilization Management Nurse to conduct prospective, concurrent, and retrospective reviews and apply clinical criteria to determine medical necessity.

You will collaborate with physician advisors to support appropriate care and payments. Based on licensure in states served and nursing credentials, you will help coordinate transitions of care, respond to inquiries, and maintain accurate documentation while adhering to privacy standards.

Qualifications

• Nursing degree required (Associate or Bachelor's).
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Active RN license in the US; multi-state licensure may be required across Idaho, Oregon, Utah, Washington.

Responsibilities

• Conducts utilization management reviews (prospective, concurrent, and retrospective) to ensure medical necessity and policy compliance.
• Applies clinical expertise and evidence-based criteria to determinations; consults with physician advisors as needed.
• Collaborates with interdisciplinary teams to facilitate transitions of care and resolve issues; responds to inquiries with timely documentation.

Skills

Communication skills

Time management

Critical thinking

Education

Associate or Bachelor’s Degree in Nursing

RN license

Tools

Microsoft Office

Outlook

Job description

Cambia Health Solutions, Inc. is seeking an experienced Utilization Management Nurse to conduct prospective, concurrent, and retrospective reviews and apply clinical criteria to determine medical necessity.

You will collaborate with physician advisors to support appropriate care and payments. Based on licensure in states served and nursing credentials, you will help coordinate transitions of care, respond to inquiries, and maintain accurate documentation while adhering to privacy standards.