Remote Utilization Management Nurse (RN)

Cambia Health Solutions, Inc.; Washington (UT); Hybrid; USD 95,928,000 - 159,603,000; Full time

Job summary

Cambia Health Solutions, Inc. is seeking a Utilization Management Nurse to join our Clinical Services team.

This remote role supports members in Oregon, Washington, Idaho or Utah, conducting prospective, concurrent and retrospective reviews to ensure medical necessity and promote cost-effective care. The candidate will collaborate across disciplines, maintain documentation, and respond to inquiries while upholding privacy and compliance standards.

Qualifications

• RN license in a US state with current, unrestricted license
• 3 years of case management or utilization management experience
• Ability to conduct assessments within scope of practice
• May require licensure in Idaho, Oregon, Utah, and Washington

Responsibilities

• Conduct utilization management reviews (prospective, concurrent, 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 to facilitate transitions of care and resolve issues
• Maintains accurate documentation and responds to inquiries

Skills

Health insurance knowledge

Communication skills

Time management

Critical thinking

Education

Associate or Bachelor's Degree in Nursing or related field

Tools

MS Office

Documentation systems

Job description

Cambia Health Solutions, Inc. is seeking a Utilization Management Nurse to join our Clinical Services team.

This remote role supports members in Oregon, Washington, Idaho or Utah, conducting prospective, concurrent and retrospective reviews to ensure medical necessity and promote cost-effective care. The candidate will collaborate across disciplines, maintain documentation, and respond to inquiries while upholding privacy and compliance standards.