Remote Utilization Management Nurse — Healthcare Impact

Cambia Health Solutions; Idaho; Remote; USD 77,000 - 104,000; Full time

Benefits offered by this job

Health insurance

Paid time off

401(k) match

Parental leave

Wellness programs

Job summary

Cambia Health Solutions is seeking a Utilization Management Nurse to join the Clinical Services team. You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and promote quality, cost-effective outcomes for members.

The position requires an active RN license, 3 years in case or utilization management, and the ability to interpret policies. We offer remote work options in several western states, a competitive salary and comprehensive benefits.

Qualifications

• Requires 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Must hold an active RN license in good standing to provide clinical care management.
• May require licensure in Idaho, Oregon, Utah and 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 make determinations and consults with physician advisors as needed.
• Collaborates with interdisciplinary teams, case management, and other departments to facilitate transitions of care.
• 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

Policy interpretation

Clinical decision making

Communication skills

Time management

Customer service

Computer skills

Education

Associate or Bachelor's Degree in Nursing or related field

RN license (unrestricted)

Tools

Microsoft Office

Outlook

Health care documentation systems

Job description

Cambia Health Solutions is seeking a Utilization Management Nurse to join the Clinical Services team. You will perform prospective, concurrent, and retrospective reviews to ensure medical necessity and promote quality, cost-effective outcomes for members.

The position requires an active RN license, 3 years in case or utilization management, and the ability to interpret policies. We offer remote work options in several western states, a competitive salary and comprehensive benefits.