Remote Utilization Management Nurse — Impact Healthcare

Cambia Health Solutions; Yakima (WA); A distancia; USD 34.000 - 45.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote or hybrid work options

Competitive benefits package

Paid time off and holidays

Descripción de la vacante

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to oversee prospective, concurrent, and retrospective reviews, ensuring medical necessity and adherence to policy. You will apply clinical criteria, collaborate with physician advisors, and support care transitions across teams.

The role emphasizes accurate documentation, timely response to inquiries, and opportunities to contribute to quality improvement while maintaining patient confidentiality in a remote work

Formación

• Associate or Bachelor’s Degree in Nursing or related field.
• 3 years of case management, utilization management, disease management, auditing or retrospective review experience.
• Equivalent combination of education and experience.
• Must have licensure or certification in a US state/territory that allows independent assessment and at least 3 years of direct clinical care.
• May need to have licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington.
• Must have at least one of the following: Bachelor’s degree in a health or human services-related field or RN license.

Responsabilidades

• Conduct utilization management reviews (prospective, concurrent, retrospective) to ensure medical necessity and policy compliance.
• Apply clinical expertise and evidence-based criteria to make determinations and consult with physician advisors as needed.
• Collaborate with interdisciplinary teams to facilitate transitions of care and resolve issues.
• Serve as a resource to internal and external customers, providing accurate and timely responses to inquiries.
• Identify opportunities for improvement and participate in quality improvement efforts.
• Maintain accurate documentation and prioritize assignments to meet performance standards and corporate goals.
• Protect confidentiality of sensitive documents and communicate professionally with members, providers, and regulatory bodies.

Conocimientos

Case management

Interpersonal communication

Analytical thinking

AI tools experience

Educación

Associate or Bachelor’s Degree in Nursing or related field

RN license (active)

Herramientas

Health care documentation systems

Microsoft Office

Descripción del empleo

Cambia Health Solutions is seeking an experienced Utilization Management Nurse to oversee prospective, concurrent, and retrospective reviews, ensuring medical necessity and adherence to policy. You will apply clinical criteria, collaborate with physician advisors, and support care transitions across teams.

The role emphasizes accurate documentation, timely response to inquiries, and opportunities to contribute to quality improvement while maintaining patient confidentiality in a remote work