Utilization Management Nurse

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

📋 Description

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

• Ensure compliance with policies and standards of care while confirming medical necessity.

• Utilize clinical expertise and evidence-based criteria for decision-making.

• Consult with physician advisors when necessary.

• Work collaboratively with interdisciplinary teams, case management, and other departments during transitions of care and to resolve issues.

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

• Deliver timely and accurate responses to inquiries.

• Identify opportunities for improvements and engage in quality enhancement initiatives.

• Maintain precise and consistent documentation.

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

• Safeguard the confidentiality of sensitive documents and matters.

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

⛳️ Requirements

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

• Minimum of 3 years of experience in case management, utilization management, disease management, auditing, or retrospective reviews.

• Equivalent combination of education and experience will 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 (or full-time equivalent) of direct clinical care experience.

• Licensure may be required for 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 RN license for medical care management.

• Knowledge of trends, technology, and contractual arrangements in the health insurance industry.

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

• Familiarity with healthcare documentation systems.

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

• Capability to interpret policies and procedures and explain complex subjects.

• Excellent organizational and time management skills.

• Ability to independently manage workload, think critically, and make decisions within assigned responsibilities.

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

• Personal mobile device required for Multi-Factor Authentication.

• Background check is mandatory.

🏝️ Benefits

• Competitive salary.

• Bonus opportunities with a 10% bonus target for Oregon, Washington, Utah, and Idaho.

• 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 policies that vary by role and tenure.

• 10 company-paid holidays.

• Leading market 401(k) plan with significant company match.

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

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

• Award-winning wellness programs that incentivize participation.

• Employee Assistance Fund available.

• Commute and parking benefits offered.

• Flexible work-from-home arrangements.

• Access to employee resource groups.

• Community outreach programs supported by Cambia.

• Wired internet connection and a personal mobile device are required for remote work and MFA access.