Remote Utilization Management Nurse — Care & Compliance

Cambia Health; Medford (OR); Remote; USD 48,000 - 79,000; Full time

Job summary

Cambia Health is seeking an Utilization Management Nurse to support prospective, concurrent and retrospective reviews from a home-based role across multiple states. The position emphasizes quality, cost-effective care and appropriate payment for services while coordinating with physicians and care teams.

The role requires an RN with 3 years of case management or related UM experience, active RN licensure, and willingness to obtain licensure in Idaho, Oregon, Utah and Washington.

Qualifications

• 3 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 assessments.
• May need licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington.
• Bachelor's degree (or higher) in a health or human services-related field or RN license with current unrestricted license.

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

Utilization management

Auditing

Retrospective review

Regulatory/compliance understanding

Communication skills

Microsoft Office

Education

Associate or Bachelor's Degree in Nursing or related field

Job description

Cambia Health is seeking an Utilization Management Nurse to support prospective, concurrent and retrospective reviews from a home-based role across multiple states. The position emphasizes quality, cost-effective care and appropriate payment for services while coordinating with physicians and care teams.

The role requires an RN with 3 years of case management or related UM experience, active RN licensure, and willingness to obtain licensure in Idaho, Oregon, Utah and Washington.