Utilization Management Nurse

🔥 12 hours ago

🥔 Idaho, Oregon, +2 more states – Remote

🥔 Idaho – Remote 🌲 Oregon – Remote ⛷️ Utah – Remote ☕ Washington – Remote

💵 $34 - $55 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

👻 Ghost score 0%

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Cambia Health Solutions

WebsiteLinkedInAll Job Openings

5001 - 10000 employees

🏥 Healthcare

⚕️ Healthcare Insurance

🤝 Non-profit

Healthcare • Healthcare Insurance • Non-profit

Cambia Health Solutions is a nonprofit, mission-driven healthcare company based in Portland, Oregon, that operates consumer-focused health care and health insurance businesses and invests in health innovation. It serves as the parent organization for the Regence family of health plans and runs initiatives and subsidiaries focused on improving care delivery, providing insurance products, and developing digital health tools and services.

📋 Description

• Conduct prospective, concurrent, and retrospective utilization management reviews • Ensure medical necessity and compliance with policy 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 • Facilitate transitions of care and resolve issues • 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 Registered Nurse (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 effectively • Strong organizational and time management skills • Ability to manage workload independently and make decisions within role responsibilities • Wired internet connection; satellite or cellular internet is not accepted • Minimum internet speed of 5 Mb upload and 10 Mb download • Access to a personal mobile device for MFA • Successful background check • Qualified applicants must meet applicable work authorization and equal opportunity requirements

🏖️ Benefits

• 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 • 10 company-paid holidays • 401(k) 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 • Wellness programs that reward participation • Employee Assistance Fund • Commute and parking benefits • Flexible work-from-home options • Bonus opportunities • Employee resource groups • Professional growth and career development opportunities • Cambia-supported community outreach programs