Remote Utilization Management Nurse: Elevate Care Outcomes

Cambia Health Solutions; Salt Lake City (UT); Remote; USD 105,447,000 - 142,697,000; Full time

Benefits offered by this job

Medical, dental and vision coverage

401(k) with company match

Paid time off

Parental leave

Wellness programs

Job summary

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to join our Clinical Services team, promoting quality and cost-effective care. You will conduct prospective, concurrent, and retrospective reviews to support medical necessity and align with policy standards.

Ideal candidates hold a nursing degree and current RN licensure, with 3+ years in case or utilization management. This role offers remote work options across multiple states and emphasizes collaboration with

Qualifications

• Associate or Bachelor’s Degree in Nursing or related field.
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Must hold US licensure/certification allowing independent assessment and 3+ years of direct clinical care.
• May require licensure in Idaho, Oregon, Utah, and Washington.
• At least one of: a health-related Bachelor's degree or RN license with current unrestricted status.

Responsibilities

• Conducts utilization management reviews (prospective, concurrent, and retrospective) to ensure medical necessity and compliance.
• Applies clinical expertise and evidence-based criteria to make determinations and consults with physician advisors as needed.
• Collaborates with interdisciplinary teams 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.
• Protects confidentiality of sensitive documents and communicates with members, providers, and regulatory organizations.

Skills

Communication skills

Time management

Critical thinking

Customer service

Policy interpretation

Education

Associate or Bachelor’s Degree in Nursing or related field

RN licensure (current, unrestricted) in US

Tools

MS Office

Health care documentation systems

Job description

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to join our Clinical Services team, promoting quality and cost-effective care. You will conduct prospective, concurrent, and retrospective reviews to support medical necessity and align with policy standards.

Ideal candidates hold a nursing degree and current RN licensure, with 3+ years in case or utilization management. This role offers remote work options across multiple states and emphasizes collaboration with