Job Description
Utilization Management Nurse
Work from home within Oregon, Washington, Idaho or 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.