Remote Utilization Management Nurse - Care Quality

Cambia Health Solutions; Utah; Remote; USD 51,000 - 69,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

HSA contributions

10 company-paid holidays

401(k) with company match

Parental leave up to 12 weeks

Wellness programs

Employee Assistance Fund

Commuter benefits

Job summary

Cambia Health Solutions is seeking a dedicated Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews, ensuring medical necessity and cost-effective care. You will collaborate with interdisciplinary teams, support transitions of care, and respond to inquiries while upholding confidentiality and high service standards.

Ideal candidates hold an RN license with 3+ years of clinical experience and are eligible in multiple states.

Qualifications

• Must have licensure or certification in a US state or territory and at least 3 years of direct clinical care.
• May need licensure in Idaho, Oregon, Utah, and Washington.
• Bachelor’s or higher in health or human services, or RN license required.

Responsibilities

• Conducts utilization management reviews to ensure medical necessity and policy adherence.
• Apply clinical criteria and consult with physician advisors as needed.
• Collaborates with teams to facilitate transitions of care and address issues.
• Responds to inquiries with accurate information to internal and external customers.
• Participates in quality improvement efforts and maintains documentation.
• Protects patient confidentiality and communicates professionally with stakeholders.
• Support statewide and local pay structures and salary ranges as applicable.

Skills

Communication

Interpersonal Skills

Organization

Critical Thinking

AI Tools

Education

Associate or Bachelor’s Degree in Nursing

RN license

Tools

Microsoft Office

Health care documentation systems

Job description

Cambia Health Solutions is seeking a dedicated Utilization Management Nurse to perform prospective, concurrent, and retrospective reviews, ensuring medical necessity and cost-effective care. You will collaborate with interdisciplinary teams, support transitions of care, and respond to inquiries while upholding confidentiality and high service standards.

Ideal candidates hold an RN license with 3+ years of clinical experience and are eligible in multiple states.