Utilization Management – Inpatient Clinical Specialist

This is a fully remote position, open to applicants in Idaho, +3 more states.

📋 Description

• Receive, investigate, and address documentation and requests pertaining to Inpatient Utilization Management cases.

• Collaborate with licensed health professionals on suitable actions and responses; this role does not involve clinical decision-making.

• Research and assess inpatient Utilization Management requests for completeness.

• Gather necessary information and complete non-clinical tasks to accurately and efficiently resolve cases.

• Communicate with both internal and external stakeholders, including providers and team members.

• Ensure written notifications are facilitated in accordance with regulatory and quality standards.

• Oversee UM activities to fulfill timeliness, production, quality, corporate, federal, state, BCBSA, and accreditation standards.

• Organize and maintain reference documents, policies, and procedures.

• Conduct thorough research and problem-solving to guarantee case accuracy and completeness.

• Recognize opportunities to enhance systems and workflows.

• Initiate referrals to related teams as necessary.

• Engage in discharge planning discussions with providers as required.

• Assist with systems testing when necessary.

⛳️ Requirements

• High school diploma or equivalent is mandatory.

• Clinical experience is essential.

• A minimum of 2 years of clinical experience is preferred.

• CMA or CNA certification is preferred.

• Clinical experience, ideally in an inpatient hospital environment.

• Strong verbal and written communication abilities.

• Proficient in computer skills including Microsoft Office, Outlook, and internet searching.

• Familiarity with healthcare systems and documentation, EMRs, billing, and claims.

• Knowledge of medical terminology, anatomy, and coding, including CPT, DX, and HCPCs.

• Demonstrated critical thinking, organizational, data entry, and administrative skills.

• Capacity to work independently with a high-volume caseload, prioritize tasks, meet deadlines, and collaborate effectively in a team setting.

• Flexibility to adapt to changes within the healthcare insurance industry.

• Commitment to maintaining confidentiality.

• Wired internet connection with a minimum of 5Mb upload and 10Mb download speeds for remote work options.

• Personal mobile device is necessary for Multi-Factor Authentication (MFA).

• Background check is required.

🏝️ Benefits

• Competitive salary.

• Market-leading 401(k) plan with a substantial company match.

• Opportunities for bonuses.

• Medical, dental, and vision insurance 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.

• Leading retirement plan with company match and potential discretionary contributions based on company performance, with no vesting period.

• Up to 12 weeks of paid parental leave following 12 months of continuous service.

• Award-winning wellness programs that incentivize participation.

• Employee Assistance Fund.

• Commute and parking benefits.

• Work-from-home options available for most positions.

• Employee resource groups.

• Community outreach programs supported by Cambia.