Utilization Management Nurse

2 weeks ago


Yakima, Washington, United States Cambia Health Solutions Full time
About the Role

Cambia Health Solutions 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 most effective and efficient healthcare possible.

Key Responsibilities
  • Conduct thorough utilization reviews to ensure medical necessity and compliance with policy and standards of care.
  • Apply clinical expertise and evidence-based criteria to make informed 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.
  • Provide accurate and timely responses to internal and external customers, serving as a resource for complex inquiries.
  • Identify opportunities for improvement and participate in quality improvement efforts to enhance our services.
  • Maintain accurate and consistent documentation, prioritizing assignments to meet performance standards and corporate goals.
  • Protect confidentiality of sensitive documents and maintain professional communication with members, providers, and regulatory organizations.
Requirements
  • Associate or Bachelor's Degree in Nursing or related field.
  • 3 years of experience in case management, utilization management, disease management, auditing, or retrospective review.
  • Equivalent combination of education and experience.
  • Licensure or certification in a health or human services discipline, with at least 3 years of direct clinical care experience.
  • Ability to interpret policies and procedures, communicate complex topics effectively, and think critically to make informed decisions.
  • Strong organizational and time management skills, with the ability to manage workload independently.
What We Offer

Cambia Health Solutions offers a competitive hourly rate of $38.00 - $41.50, depending on experience. We are a remote-friendly organization, and this role can be performed from home. If you are a motivated and detail-oriented nurse with a passion for healthcare, we encourage you to apply for this exciting opportunity.



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