Utilization Management Nurse (Future Opportunities)

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.

**Please note this role is a candidate pool, and we are always looking for top talent. We do not always have open positions but we encourage you to submit your resume so you will be considered for all open roles.**

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)

#LI-Remote

Base pay is just part of the compensation package at Cambia that is supplemented with an exceptional 401(k) match, bonus opportunity and other benefits. In keeping with our Cause and vision, we offer comprehensive well-being programs and benefits, which we periodically update to stay current. Some highlights:

• medical, dental, and vision coverage for employees and their eligible family members

• annual employer contribution to a health savings account ($1,200 or $2,500 depending on medical coverage, prorated based on hire date)

• paid time off varying by role and tenure in addition to 10 company holidays

• up to a 6% company match on employee 401k contributions, with a potential discretionary contribution based on company performance (no vesting period)

• up to 12 weeks of paid parental time off (eligible day one of employment if within first 12 months following birth or adoption)

• one-time furniture and equipment allowance for employees working from home

• up to $225 in Amazon gift cards for participating in various well-being activities. for a complete list see our External Total Rewards page.