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Clinical Utilization Management Nurse
2 months ago
As a pivotal member of the Clinical Services team, the Utilization Management Nurse plays a crucial role in ensuring that healthcare services align with members' needs while promoting quality and cost-effective outcomes.
Key Responsibilities:
- Conduct utilization management evaluations, including prospective, concurrent, and retrospective reviews, to validate medical necessity and adherence to established policies and standards.
- Utilize clinical expertise and evidence-based criteria to make informed decisions, collaborating with physician advisors as necessary.
- Engage with interdisciplinary teams and case management to facilitate seamless transitions of care and address any arising issues.
- Serve as a reliable resource for both internal and external stakeholders, delivering accurate and timely information in response to inquiries.
- Identify areas for enhancement and actively participate in quality improvement initiatives.
- Maintain precise and consistent documentation while prioritizing tasks to meet performance metrics and organizational objectives.
- Safeguard the confidentiality of sensitive information while communicating professionally with members, providers, and regulatory bodies.
Qualifications:
Applicants should possess an Associate or Bachelor's Degree in Nursing or a related field, with a minimum of three years of experience in case management, utilization management, disease management, auditing, or retrospective review. Licensure or certification in a relevant health or human services discipline is required, allowing for independent assessments as permitted by the scope of practice.
Preferred qualifications include:
- A Bachelor's degree or higher in a health or human services-related field, with a preference for psychiatric RN or a Master's degree in Behavioral Health for behavioral health roles.
- A current, unrestricted Registered Nurse (RN) license for medical care management.
Skills and Attributes:
- Comprehensive understanding of health insurance industry trends and technology.
- Proficient in general computer skills, including Microsoft Office and healthcare documentation systems.
- Exceptional verbal, written, and interpersonal communication skills.
- Strong organizational abilities and time management skills, with the capacity to manage workload independently.
- Critical thinking skills to make informed decisions within the scope of responsibilities.
Compensation and Benefits:
The expected compensation for this role is competitive, with an hourly rate based on skills, experience, and education. Additional benefits include:
- Comprehensive medical, dental, and vision coverage for employees and eligible family members.
- Annual contributions to a health savings account.
- Generous paid time off and company-paid holidays.
- A market-leading retirement plan with a significant company match.
- Paid parental leave and wellness programs.
About Cambia Health Solutions:
Cambia is dedicated to creating a sustainable, person-focused healthcare system. Our team is committed to innovation and excellence, working collaboratively to enhance the healthcare experience for our members.
