Utilization Management Nurse
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Job Description
Utilization Management Nurse conducting clinical utilization reviews for Cambia’s person-focused healthcare system. Applying evidence-based criteria and coordinating transitions of care remotely across four states.
Responsibilities:
- Conduct prospective, concurrent, and retrospective utilization management reviews
- Ensure medical necessity and compliance with policies and standards of care
- Apply clinical expertise and evidence-based criteria to make determinations
- Consult with physician advisors as needed
- Collaborate with interdisciplinary teams, case management, and other departments on transitions of care and issue resolution
- Serve as a resource to internal and external customers
- Provide accurate and timely responses to inquiries
- Identify improvement opportunities and participate in quality improvement efforts
- Maintain accurate and consistent documentation
- Prioritize assignments to meet performance standards and corporate goals
- Protect confidentiality of sensitive documents and issues
- Communicate professionally with members, providers, and regulatory organizations
Requirements:
- 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
- Licensure or certification in a state or territory of the United States in a health or human services discipline allowing independent assessments within scope of practice
- At least 3 years (or full-time equivalent) of direct clinical care
- May need licensure in Idaho, Oregon, Utah, and Washington
- At least one of: Bachelor’s degree or higher in a health or human services-related field, or current unrestricted RN license for medical care management
- Knowledge of health insurance industry trends, technology, and contractual arrangements
- General computer skills, including Microsoft Office, Outlook, and internet search
- Familiarity with health care documentation systems
- Strong verbal, written, interpersonal communication, and customer service skills
- Ability to interpret policies and procedures and communicate complex topics
- Strong organizational and time management skills
- Ability to manage workload independently, think critically, and make decisions within role responsibilities
- Wired internet connection that is not satellite or cellular, with minimum 5 Mb upload and 10 Mb download speeds
- Personal mobile device for Multi-Factor Authentication
- Background check required
Benefits:
- Competitive salary
- Bonus opportunities; 10% bonus target for Oregon, Washington, Utah, and Idaho
- Medical, dental and vision coverage for employees and eligible family members, including mental health benefits
- Annual employer contribution to a health savings account
- Generous paid time off varying by role and tenure
- 10 company-paid holidays
- Market-leading 401(k) with significant company match
- Potential discretionary retirement contribution based on company performance, with no vesting period
- Up to 12 weeks of paid parental time off after 12 months of continuous service
- Award-winning wellness programs that reward participation
- Employee Assistance Fund
- Commute and parking benefits
- Flexible work-from-home options
- Employee resource groups
- Cambia-supported community outreach programs
- Wired internet connection and personal mobile device required for remote-work and MFA access
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