Utilization Management Nurse

Cambia Health Solutions•Yakima, WA

1d•$32 - $57•Remote

About The Position

Cambia’s Utilization Management Nurse is part of the Clinical Services team and provides prospective, concurrent, and retrospective utilization management reviews to address members’ healthcare needs, promote quality and cost-effective outcomes, and support appropriate payment for services. The role applies clinical expertise and evidence-based criteria to assess medical necessity and compliance with policies and standards of care, consulting physician advisors as needed. It collaborates with interdisciplinary teams, case management, and other departments to support transitions of care and resolve issues, while serving as a resource to internal and external customers. The position is work from home within Oregon, Washington, Idaho, or Utah; preference is given to current employees and candidates residing in Idaho or Utah. Remote employees must have wired, non-satellite and non-cellular internet service with minimum upload speed of 5 Mb and download speed of 10 Mb. New hires need access to a personal mobile device to set up required multi-factor authentication. A background check is required.

Requirements

Associate or bachelor’s degree in nursing or a related field, or an equivalent combination of education and experience.
At least 3 years of case management, utilization management, disease management, auditing, or retrospective review experience.
Licensure or certification in a U.S. state or territory in a health or human services discipline that allows independent assessment within the discipline’s scope of practice, and at least 3 years (or full-time equivalent) of direct clinical care.
At least one of the following: a bachelor’s degree or higher in a health or human services-related field, or a current unrestricted RN license for medical care management.
May need licensure in all four states served by Cambia: Idaho, Oregon, Utah, and Washington.
Knowledge of health insurance industry trends, technology, and contractual arrangements.
General computer skills, including Microsoft Office, Outlook, and internet search, and familiarity with healthcare documentation systems.
Strong verbal, written, interpersonal communication, and customer service skills.
Ability to interpret policies and procedures and communicate complex topics effectively.
Strong organizational and time-management skills, including the ability to manage workload independently.
Ability to think critically and make decisions within the scope of the role and responsibility.
Access to a personal mobile device for required multi-factor authentication upon joining.
For remote work, wired internet service that is not satellite or cellular, with at least 5 Mb upload and 10 Mb download speeds.

Nice To Haves

For behavioral health, a psychiatric RN or a master’s degree in behavioral health is preferred.
Preference will be given to current employees and candidates who reside in Idaho or Utah.

Responsibilities

Conduct prospective, concurrent, and retrospective utilization management reviews to ensure medical necessity and compliance with policy and standards of care.
Apply clinical expertise and evidence-based criteria to make determinations, consulting physician advisors as needed.
Collaborate with interdisciplinary teams, case management, and other departments to facilitate transitions of care and resolve issues.
Provide accurate and timely responses to inquiries as a resource to internal and external customers.
Identify opportunities for improvement and participate in quality improvement efforts.
Maintain accurate and consistent documentation and prioritize assignments to meet performance standards and corporate goals.
Protect confidential and sensitive documents and information while communicating professionally with members, providers, and regulatory organizations.

Benefits

Medical, dental, and vision coverage for employees and eligible family members, including mental health benefits.
Annual employer contribution to a health savings account.
Paid time off that varies by role and tenure, plus 10 company-paid holidays.
401(k) retirement plan with company match and potential discretionary contribution based on company performance, with no vesting period.
Up to 12 weeks of paid parental time off, subject to eligibility requirements.
Wellness programs with participation rewards.
Employee Assistance Fund.
Commute and parking benefits.
Bonus opportunities; stated bonus target is 8%.
Competitive base pay.