Utilization Management Nurse

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

📋 Description

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

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

• Leverage clinical expertise and evidence-based criteria to make informed decisions.

• Engage with physician advisors as necessary.

• Collaborate with interdisciplinary teams, case management, and other departments to ensure seamless transitions of care and address any issues.

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

• Deliver accurate and timely responses to inquiries.

• Identify areas for enhancement and take part in quality improvement initiatives.

• Maintain precise and consistent documentation.

• Prioritize tasks to meet performance standards and corporate objectives.

• Safeguard the confidentiality of sensitive documents and issues.

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

⛳️ Requirements

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

• A minimum of 3 years’ experience in case management, utilization management, disease management, auditing, or retrospective review.

• An equivalent combination of education and experience may be considered.

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

• At least 3 years of direct clinical care experience.

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

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

• Preference for candidates with a Psychiatric RN qualification or a Master’s degree in Behavioral Health for behavioral health roles.

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

• Proficiency in general computer skills, including Microsoft Office, Outlook, and internet research.

• Familiarity with healthcare documentation systems.

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

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

• Strong organizational and time management skills.

• Ability to manage workload independently.

• Proficient in critical thinking and decision-making.

• Background check is mandatory.

• A wired internet connection (not satellite or cellular) with a minimum upload speed of 5Mb and download speed of 10Mb is required.

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

🏝️ Benefits

• Competitive salary.

• Bonus opportunities with an 8% bonus target.

• 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.

• Market-leading retirement plan with company match on employee 401(k) contributions.

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

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

• Award-winning wellness programs that incentivize participation.

• Employee Assistance Fund.

• Commute and parking benefits.

• Work-from-home options.

• Employee resource groups.

• Community outreach programs supported by Cambia.

• Wired internet connection and minimum internet speeds required for the work-from-home option.

• Support for personal mobile devices for Multi-Factor Authentication.