Utilization Management Nurse

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

Work from home within Oregon, Washington, Idaho or Utah

Preference will be given to current employees and candidates who reside in Idaho and Utah

Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Who We Are Looking For

Every day, Cambia’s dedicated team of Nurses are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Utilization Management Nurses provide utilization management (such as prospective concurrent and retrospective review) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services – all in service of making our members’ health journeys easier.

Are you a Nurse who has a passion for healthcare? Are you a Nurse who is ready to take your career to the next level and make a real difference in the lives of our members? Then this role may be the perfect fit.

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
• Equivalent combination of education and experience
• Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline (e.g. medical vs. behavioral health) and at least 3 years (or full time equivalent) 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 (or higher) in a health or human services-related field (psychiatric RN or Masters’ degree in Behavioral Health preferred for behavioral health); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management)

Skills And Attributes

• Knowledge of health insurance industry trends, technology and contractual arrangements.
• General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.
• Strong verbal, written and interpersonal communication and customer service skills.
• Ability to interpret policies and procedures and communicate complex topics effectively.
• Strong organizational and time management skills with the ability to manage workload independently.
• Ability to think critically and make decisions within individual role and responsibility.

What You Will Do At Cambia

• Conducts utilization management reviews (prospective, concurrent, and retrospective) to ensure medical necessity and compliance with policy and standards of care.
• 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 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 and corporate goals.
• Protects confidentiality of sensitive documents and issues while communicating professionally with members, providers, and regulatory organizations.

Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.

• Oregon, Washington, Utah, and Idaho: The expected hiring range is $36.80 – $49.80 an hour, the full salary range is $34.20 – $55.70 an hour and the bonus target is 10%.
• North Dakota: The expected hiring range is $35.21 - $47.63 an hour and the full salary range is $31.86 - $50.98 an hour.

About Cambia

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Why Join the Cambia Team?

At Cambia, You Can

• Work alongside diverse teams building cutting-edge solutions to transform health care.
• Earn a competitive salary and enjoy generous benefits while doing work that changes lives.
• Grow your career with a company committed to helping you succeed.
• Give back to your community by participating in Cambia-supported outreach programs.
• Connect with colleagues who share similar interests and backgrounds through our employee resource groups.

We believe a career at Cambia is more than just a paycheck – and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.

Benefits

In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits.
• Annual employer contribution to a health savings account.
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays.
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period).
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave).
• Award-winning wellness programs that reward you for participation.
• Employee Assistance Fund for those in need.
• Commute and parking benefits.

Learn More About Our Benefits.

We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.

As part of our security requirements, new hires will need access to a personal mobile device to set up Multi-Factor Authentication (MFA) upon joining the company. MFA is an important layer of protection for accessing Cambia systems and is required for all employees.

We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.

If you need accommodation for any part of the application process because of a medical condition or disability, please email [e-mail]. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.