Clinical Services Specialist

7 hours ago


Boise, Idaho, United States Cambia Health Full time
About the Role

Cambia Health is seeking a skilled Utilization Management Nurse to join our Clinical Services team. As a key member of our team, you will play a critical role in ensuring that our members receive the highest quality care while promoting cost-effective outcomes.

Key Responsibilities
  • Conduct thorough 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.
What We Offer

Cambia Health offers a competitive salary and generous benefits package, as well as opportunities for professional growth and development. If you are a motivated and detail-oriented individual with a passion for healthcare, we encourage you to apply for this exciting opportunity.



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