Remote Utilization Management Nurse (RN)

Cambia Health; Salem (OR); Remote; USD 48,000 - 79,000; Full time

Benefits offered by this job

Medical benefits

Paid time off

401(k) retirement plan

Job summary

Cambia Health is seeking an Utilization Management Nurse who can conduct prospective, concurrent, and retrospective reviews to ensure medical necessity and proper care pathways. You will apply evidence-based criteria and consult with physicians as needed.

In this role, you will collaborate with case management and other departments, support transitions of care, and maintain compliant, accurate documentation while serving members, providers, and regulatory bodies.

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 have licensure/certification in a U.S. state
• Licensure in all four states Cambia serves (Idaho, Oregon, Utah, Washington) if required.

Responsibilities

• Conduct utilization management reviews (prospective, concurrent, retrospective).
• Apply clinical criteria to determine medical necessity and consult physician advisors as needed.
• Collaborate with interdisciplinary teams to facilitate transitions of care.
• Provide accurate, timely responses to inquiries and maintain documentation.

Skills

Health insurance trends

Communication skills

Time management

Education

Nursing degree (ADN/BSN)

RN license (state licensure)

Tools

Microsoft Office

Healthcare documentation systems

Job description

Cambia Health is seeking an Utilization Management Nurse who can conduct prospective, concurrent, and retrospective reviews to ensure medical necessity and proper care pathways. You will apply evidence-based criteria and consult with physicians as needed.

In this role, you will collaborate with case management and other departments, support transitions of care, and maintain compliant, accurate documentation while serving members, providers, and regulatory bodies.