Supervisor Utilization Management

Cambia Health Solutions•Medford, OR

2d•$90,907 - $142,000•Hybrid

About The Position

This is a hybrid role with 3 days/week in the office, located in Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston, or Fargo. Candidates must reside within commutable distance of a listed location or be willing to relocate. The role is part of the Clinical Services leadership team, supervising Utilization Management (UM) Leaders and acting as a resource for UM professional and support staff. The position 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. It may also be responsible for ensuring that medical payments are appropriate and in alignment with contract provisions, proper coding and policy compliance. The role requires a willingness to learn and grow in leadership, supporting the team and the members they serve.

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.
Competitive base pay
Market-leading 401(k) with a significant company match
Bonus opportunities