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Utilization Management Nurse - Remote within ID, OR, WA, or UT

Company: Cambia Health
Location: Burlington
Posted on: November 26, 2022

Job Description:

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 services.

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 patient.

* 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 determinations.

* 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 timelines.

Minimum Requirements

* 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.

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 Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy. As a health care company, we are committed to 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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