Utilization Management Nurse - Remote within ID, OR, WA, or UT
Company: Cambia Health
Posted on: November 26, 2022
Utilization Management Nurse
Remote within ID, OR, WA, or UT. Candidates outside of these states
will not be considered.
Primary Job Purpose
The Utilization Management Nurse provides 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
General Functions and Outcomes
* The Utilization Management Nurse is responsible for review in one
or more of the following areas: prospective: Utilization management
conducted prior to a patient's admission, stay, or other service or
course of treatment (including outpatient procedures and services).
Sometimes called "precertification review" or "prior
authorization," prospective review can include prospective
prescription drug utilization review.; concurrent: Utilization
management conducted during a patient's hospital stay or course of
treatment (including outpatient procedures and services). Sometimes
called "continued stay review".
* Retrospective: Review conducted after services (including
outpatient procedures and services) have been provided to the
* Applies clinical expertise and judgment to ensure compliance with
medical policy, medical necessity guidelines, and accepted
standards of care. Utilizes evidence-based criteria that
incorporates current and validated clinical research findings.
Practices within the scope of their license.
* Consults with physician advisors to ensure clinically appropriate
* May facilitate transitions of care through collaboration with the
member, the facilities interdisciplinary team and Regence's Case
Management to achieve optimal recovery for the member.
* Serves as a resource to internal and external customers.
* Collaborates with other departments to resolve claims, quality of
care, member or provider issues.
* Identifies problems or needed changes, recommends resolution, and
participates in quality improvement efforts.
* Responds in writing, by phone, or in person to members, providers
and regulatory organizations in a professional manner while
protecting confidentiality of sensitive documents and issues.
* Provides consistent and accurate documentation.
* Plans, organizes and prioritizes assignments to comply with
performance standards, corporate goals, and established
* Knowledge of health insurance industry trends, technology and
* General computer skills (including use of Microsoft Office,
Outlook, internet search). Familiarity with health care
* 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.
Normally to be proficient in the competencies listed above
Utilization Management Nurse would have a/an Associate or
Bachelor's Degree in Nursing or related field and 3 years of case
management, utilization management, disease management, auditing or
retrospective review experience or equivalent combination of
education and experience.
Required Licenses, Certifications, Registration, Etc.
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.
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)
At Cambia, we are dedicated to making the health care experience
simpler, better, and more affordable for people and their families.
This family of over a dozen companies works together to make the
health care system more economically sustainable and efficient.
Cambia's solutions empower over 80 million Americans nationwide,
including more than 3.4 million people in the Pacific Northwest,
who are enrolled in Cambia's regional health plans.
Cambia is a total health solutions company that is deeply rooted in
a 100-year legacy of transforming the industry and the way people
experience health care. We had our beginnings in the logging
communities of the Pacific Northwest as innovators in helping
workers afford health care. That pioneering spirit has kept us at
the forefront as we build new avenues to improve access to and
quality of health care for the future. Cambia is committed to
delivering a seamless, personalized health care experience for the
next 100 years.
This position includes 401(k), healthcare, paid time off, paid
holidays, and more. For more information, please visit
We are an Equal Opportunity and Affirmative Action employer
dedicated to workforce diversity and a drug and tobacco-free
workplace. All qualified applicants will receive consideration for
employment without regard to race, color, national origin,
religion, age, sex, sexual orientation, gender identity,
disability, protected veteran status or any other status protected
by law. A background check is required.
If you need accommodation for any part of the application process
because of a medical condition or disability, please email
CambiaCareers@cambiahealth.com. Information about how Cambia Health
Solutions collects, uses, and discloses information is available in
the health of our communities and employees during the COVID-19
pandemic. Please review the policy on our Careers site.
Keywords: Cambia Health, Bellingham , Utilization Management Nurse - Remote within ID, OR, WA, or UT, Healthcare , Burlington, Washington
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