Utilization Management Nurse

Cambia Health Solutions • Lewiston, ID

8d • Remote

About The Position

Cambia’s Utilization Management Nurses are part of the Clinical Services team and provide prospective, concurrent, and retrospective utilization management reviews. The role helps meet members’ specific healthcare needs, promote quality and cost-effective outcomes, and ensure appropriate payment for services. Nurses apply clinical expertise and evidence-based criteria to determine medical necessity and compliance with policies and standards of care, consulting physician advisors when needed.

This position works from home within Oregon, Washington, Idaho, or Utah. Preference is given to current employees and candidates who reside in Idaho or Utah. The role collaborates with interdisciplinary teams, case management, and other departments; supports internal and external customers; contributes to quality improvement; and maintains accurate documentation while protecting confidential information. A wired, non-satellite and non-cellular internet connection is required, with at least 5 Mbps upload and 10 Mbps download speeds. New hires need access to a personal mobile device for multifactor authentication.

Requirements

• Associate or bachelor’s degree in nursing or a related field, or an equivalent combination of education and experience.
• Three 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 permits independent assessment within the discipline’s scope of practice.
• At least three 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 registered nurse (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.

Nice To Haves

• Psychiatric RN or a master’s degree in behavioral health is preferred for behavioral health work.
• Current employees and candidates residing in Idaho or Utah are preferred.

Responsibilities

• Conduct prospective, concurrent, and retrospective utilization management reviews to ensure medical necessity and compliance with policies and standards of care.
• Apply clinical expertise and evidence-based criteria to make determinations and consult physician advisors as needed.
• Collaborate with interdisciplinary teams, case management, and other departments to facilitate transitions of care and resolve issues.
• Serve as a resource to internal and external customers by providing accurate and timely responses to inquiries.
• 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 documents and information, 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) plan with company match and a potential discretionary contribution based on company performance; no vesting period.
• Bonus opportunities.
• 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.
• Employee resource groups and opportunities to participate in company-supported community outreach programs.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Education Level: Associate degree