Remote Utilization Management Nurse – Care That Counts

Cambia Health Solutions; Coeur d'Alene (ID); Remote; USD 100,289,000 - 163,328,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

Retirement plan with company match

Paid time off

Work-from-home options

Job summary

Cambia Health Solutions is hiring a Nurse for Utilization Management to perform prospective, concurrent, and retrospective reviews ensuring medical necessity and policy compliance. You will apply clinical judgment, consult with physician advisors, and coordinate with care teams to support smooth transitions and quality outcomes.

The role emphasizes documentation, timely responses, and participation in improvement efforts, with remote work options and state licensure requirements across Idaho,

Qualifications

• RN license in at least one state.
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Must have licensure/certification for independent assessment in health or human services discipline.

Responsibilities

• Conducts utilization management reviews (prospective, concurrent, retrospective) to ensure medical necessity.
• Applies clinical expertise and evidence-based criteria to determinations and consults with physician advisors.
• Collaborates with interdisciplinary teams to facilitate transitions of care.
• Provides accurate and timely responses to inquiries from internal/external customers.
• Identifies opportunities for quality improvement and participates in initiatives.

Skills

Nursing licensure

Case management

Utilization management

Healthcare claims knowledge

MS Office

Outlook

Healthcare documentation systems

Critical thinking

Education

Associate or Bachelor’s Degree in Nursing

RN licensure in applicable states

Tools

Microsoft Office

Outlook

Healthcare documentation systems

Job description

Cambia Health Solutions is hiring a Nurse for Utilization Management to perform prospective, concurrent, and retrospective reviews ensuring medical necessity and policy compliance. You will apply clinical judgment, consult with physician advisors, and coordinate with care teams to support smooth transitions and quality outcomes.

The role emphasizes documentation, timely responses, and participation in improvement efforts, with remote work options and state licensure requirements across Idaho,