Supervisor Utilization Management

Cambia Health Solutions • Lewiston, ID

20h • Hybrid

About The Position

Supervisor Utilization Management Hybrid role (3 days/week in office) at our Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston, or Fargo offices. Candidates must reside within commutable distance of that location or be willing to relocate. 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 Utilization Management (UM) Leaders are living our mission to make health care easier and lives better. As a member of the Clinical Services leadership team, our Supervisor Utilization Management supervises the team and acts as a resource for utilization management professional and support staff. Oversees and coordinates team activities to achieve business objectives and ensure medically necessary, cost-effective, quality care is delivered to members through various utilization management programs, including prior authorization and inpatient concurrent review, and regulatory compliance. May also be responsible for ensuring that medical payments are appropriate and in alignment with contract provisions, proper coding and policy compliance – all in service of making our members’ health journeys easier. As a people leader, you are willing to learn and grow, understanding that leadership is a craft that is continuously honed as you support your team and the lives that depend upon us. What if your clinical expertise and leadership instincts could shape the standard of care for an entire team — and thousands of members at once? Are you a clinical professional who finds yourself naturally stepping up to guide others, streamline processes, and ask 'how do we make this better for the patient? Then this role may be the perfect fit.

Requirements

• Bachelor's degree in Nursing or related field
• 3 years of leadership experience
• 5 years of clinical experience or equivalent combination of education and experience.
• Must have license or certification, in a state or territory of the United States in the health or human services-related field that allows the professional to conduct an assessment as permitted within the scope of practice of the discipline (e.g. medical vs. behavioral health)
• 3 years full time equivalent direct clinical care
• Current unrestricted Registered Nurse (RN) license in a state or territory of the United States

Nice To Haves

• Familiarity with health insurance industry trends and technology.
• Demonstrated competency related to clinical utilization management and care management practices.
• Ability to apply best practices and designated standards.
• Knowledge of payment coding guidelines, as applicable (Payment Review only).
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Responsibilities

• Assigns and prioritizes work, sets goals, and coordinates daily activities of the team.
• Provides regular updates and communication to staff through 1:1 and team meetings.
• Monitors individual and team results to ensure work is completed in a timely manner, in accordance with department standards and procedures, and is in compliance with medical policy and medical necessity guidelines.
• Assists in development of productivity and quality standards.
• May conduct or participate in compliance audits and report audit findings.
• Identifies and implements process improvements as needed.
• Acts as a resource for staff and others.
• Appropriately escalates issues and partners with other departments to resolve issues and remove barriers.
• Collaborates with physician advisors on complex case and coverage determination processes.
• Participates in the hiring process, provides on-going coaching, employee development and writing of performance reviews.
• Develops and maintains desk reference guides on work procedures.
• Ensures new hires complete necessary training.
• Assesses training needs and plays an active role in development of staff.
• Completes special projects as assigned and may provide back-up support to staff as needed.
• Maintains clinical competency and keeps current on medical practices, procedures and industry trends.
• May develop and present educational updates internally or to other departments.
• Seeks ideas and opportunities for continuous improvement, determines which opportunities should be pursued and implements improvements as appropriate.

Benefits

• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager