Healthcare Utilization Specialist

4 weeks ago

Vancouver, Washington, United States Cambia Health Solutions Full time
Job Description

Job Title: Utilization Management Nurse

Job Summary: We are seeking a skilled Utilization Management Nurse to join our Clinical Services team. As a Utilization Management Nurse, you will play a critical role in ensuring that our members receive the necessary healthcare services while promoting quality and cost-effective outcomes.

Key Responsibilities:

  • Conduct utilization management reviews to ensure medical necessity and compliance with policy and standards of care.
  • Apply clinical expertise and evidence-based criteria to make determinations and consult with physician advisors as needed.
  • Collaborate with interdisciplinary teams, case management, and other departments to facilitate transitions of care and resolve issues.
  • Serve as a resource to internal and external customers, providing accurate and timely responses to inquiries.
  • Identify opportunities for improvement and participate in quality improvement efforts.
  • Maintain accurate and consistent documentation and prioritize assignments to meet performance standards and corporate goals.
  • Protect confidentiality of sensitive documents and issues while communicating 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.
  • Must have licensure or certification, in a state or territory of the United States, in a health or human services discipline that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline.
  • May need to have licensure in all four states served by Cambia: Idaho, Oregon, Utah, Washington.

Preferred Qualifications:

  • Bachelor's degree (or higher) in a health or human services-related field (psychiatric RN or Masters' degree in Behavioral Health preferred for behavioral health); or Registered nurse (RN) license (must have a current unrestricted RN license for medical care management).
  • Knowledge of health insurance industry trends, technology and contractual arrangements.
  • General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems.

About Cambia: Cambia Health Solutions is a leading health solutions company dedicated to making healthcare easier and lives better. We are committed to creating a person-focused and economically sustainable healthcare system.

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