Utilization Management Nurse

Cambia Health Solutions, Inc.; United States; Hybrid; USD 51,000 - 69,000; Full time

Benefits offered by this job

Work from home options

Medical, dental and vision coverage

Competitive retirement plan & 401(k)

Job summary

Cambia Health Solutions, Inc. is seeking an Utilization Management Nurse to support prospective, concurrent, and retrospective reviews from a home-based role across Oregon, Washington, Idaho, and Utah.

The job emphasizes independent clinical assessment and collaboration with care teams to ensure medically necessary, cost-effective care. The ideal candidate holds a nursing degree with an active RN license and at least three years in utilization management or related fields, with flexibility for

Qualifications

• Nursing degree or related field with active license in US
• 3 years of case management or utilization management or related experience
• Ability to conduct assessments independently within scope of practice (medical/behavioral health)
• May require licensure in all four Cambia states: ID, OR, UT, WA

Responsibilities

• Conducts utilization management reviews (prospective, concurrent, retrospective) to ensure medical necessity and policy compliance
• Applies clinical expertise and evidence-based criteria to make determinations; consults with physician advisors as needed
• Collaborates with interdisciplinary teams to facilitate transitions of care and resolve issues
• Provides timely responses to inquiries and maintains accurate documentation

Skills

Health insurance industry knowledge

MS Office & Outlook

Verbal & written communication

Policy interpretation

Time management

Education

Associate or Bachelor's in Nursing

RN license or equivalent certification

Tools

Microsoft Office

Health care documentation systems

Job description

Utilization Management Nurse### Utilization Management NurseApply: Lewiston, ID: Salt Lake City, UT: Medford, OR: Coeur d'Alene, ID: Burlington, WA: Full time: Posted Yesterday: R-7046## **Utilization Management Nurse****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.**What You Bring to Cambia:****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. #LI-RemotePay 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. National pay structure — applies to the Boise, Portland, Salem, Seattle/Renton/Tacoma, Burlington, Vancouver, and Salt Lake City metro areas. The full salary range is $35.00 - $57.00 and the bonus target is 8%. The expected salary range is $37.20 - $50.40. Regional pay structure — applies to North Dakota and to Idaho, Oregon, Washington, and Utah locations outside the metro areas listed above. The full salary range is $31.50 - $51.30 and the bonus target is 8%. The expected salary range is $33.50 - $45.30.**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. 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.