Utilization Management Nurse

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

📋 Description

• Conduct reviews for prospective, concurrent, and retrospective utilization management.

• Ensure adherence to medical necessity and compliance with relevant policies and standards of care.

• Utilize clinical expertise and evidence-based criteria to make informed determinations.

• Consult with physician advisors when necessary.

• Collaborate with interdisciplinary teams, case management, and various departments.

• Facilitate transitions of care and address any arising issues.

• Act as a resource for both internal and external customers.

• Provide timely and accurate responses to inquiries.

• Identify areas for improvement and engage in quality enhancement initiatives.

• Maintain precise and consistent documentation.

• Prioritize tasks to align with performance standards and corporate objectives.

• Safeguard the confidentiality of sensitive documents and issues.

• Communicate professionally with members, providers, and regulatory agencies.

⛳️ Requirements

• Associate or Bachelor’s Degree in Nursing or a related field.

• Three years of experience in case management, utilization management, disease management, auditing, or retrospective review.

• An equivalent combination of education and experience is acceptable.

• Licensure or certification in a state or territory of the United States in a health or human services discipline that permits independent assessments within the scope of practice.

• A minimum of three years (or its full-time equivalent) of direct clinical care experience.

• Licensure may be required in Idaho, Oregon, Utah, and Washington.

• At least one of the following: a Bachelor’s degree or higher in a health or human services-related field, or a current unrestricted Registered Nurse (RN) license for medical care management.

• Understanding of trends, technology, and contractual agreements within the health insurance industry.

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

• Familiarity with healthcare documentation systems.

• Excellent verbal, written, interpersonal communication, and customer service skills.

• Ability to interpret policies and procedures and convey complex topics effectively.

• Strong organizational and time management capabilities.

• Capacity to manage workload independently and make decisions within the role's responsibilities.

• A reliable wired internet connection; satellite or cellular internet is not acceptable.

• Minimum internet speed of 5 Mb upload and 10 Mb download.

• Access to a personal mobile device for multi-factor authentication (MFA).

• Successful completion of a background check.

• Qualified applicants must fulfill applicable work authorization and equal opportunity criteria.

🏝️ Benefits

• Medical, dental, and vision coverage for employees and eligible family members, including mental health support.

• Annual employer contribution to a health savings account.

• Generous paid time off policy.

• 10 company-paid holidays each year.

• 401(k) matching contributions from the company.

• Potential discretionary retirement contributions based on company performance, with no vesting period required.

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

• Wellness programs that incentivize participation.

• Employee Assistance Fund available.

• Commute and parking benefits provided.

• Flexible work-from-home options available.

• Opportunities for bonuses.

• Employee resource groups supported.

• Professional growth and career development opportunities offered.

• Community outreach programs supported by Cambia.