Utilization Management Nurse

Cambia Health Solutions

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

Posted 9/22/2026full-timeRemote • United StatesMid-LevelSenior💰 $34 - $56 per hourWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in Utilization Management and Case Management, applying clinical knowledge to ensure medical necessity and compliance. Proficient in collaborating with interdisciplinary teams and maintaining accurate documentation while providing exceptional customer service.

Highest-signal resume keywords

Utilization ManagementCase ManagementClinical ExpertiseRegistered Nurse (RN) LicenseHealth Insurance Industry Knowledge

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Utilization Management ReviewsClinical CareQuality ImprovementHealth Care Documentation SystemsEvidence-Based Criteria Application

Soft Skills

Interpersonal CommunicationOrganizational SkillsTime ManagementCustomer ServiceProfessional Communication

Tools & Technologies

Microsoft OfficeOutlookInternet Search

Certifications & Qualifications

Licensure in Health or Human Services Discipline

Industry Keywords

Medical NecessityCompliance StandardsTransitions of CarePerformance StandardsConfidentiality

About the role

Key responsibilities & impact

Conduct prospective, concurrent, and retrospective utilization management reviews
Ensure medical necessity and compliance with policy and standards of care
Apply clinical expertise and evidence-based criteria to make determinations
Consult with physician advisors as needed
Collaborate with interdisciplinary teams, case management, and other departments
Facilitate transitions of care and resolve issues
Serve as a resource to internal and external customers
Provide accurate and timely responses to inquiries
Identify improvement opportunities and participate in quality improvement efforts
Maintain accurate and consistent documentation
Prioritize assignments to meet performance standards and corporate goals
Protect confidentiality of sensitive documents and issues
Communicate professionally with members, providers, and regulatory organizations

Requirements

What you’ll need

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
Licensure or certification in a state or territory of the United States in a health or human services discipline allowing independent assessments within scope of practice
At least 3 years (or full-time equivalent) of direct clinical care
May need licensure in Idaho, Oregon, Utah, and Washington
At least one of: Bachelor’s degree or higher in a health or human services-related field, or current unrestricted Registered Nurse (RN) license for medical care management
Knowledge of health insurance industry trends, technology, and contractual arrangements
General computer skills, including Microsoft Office, Outlook, and internet search
Familiarity with health care documentation systems
Strong verbal, written, interpersonal communication, and customer service skills
Ability to interpret policies and procedures and communicate complex topics effectively
Strong organizational and time management skills
Ability to manage workload independently and make decisions within role responsibilities
Wired internet connection; satellite or cellular internet is not accepted
Minimum internet speed of 5 Mb upload and 10 Mb download
Access to a personal mobile device for MFA
Successful background check
Qualified applicants must meet applicable work authorization and equal opportunity requirements

Benefits

Comp & perks

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
10 company-paid holidays
401(k) company match
Potential discretionary retirement contribution based on company performance, with no vesting period
Up to 12 weeks of paid parental time off after 12 months of continuous service
Wellness programs that reward participation
Employee Assistance Fund
Commute and parking benefits
Flexible work-from-home options
Bonus opportunities
Employee resource groups
Professional growth and career development opportunities
Cambia-supported community outreach programs