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Utilization and Care Management Nurse

Company: Cambia Health Solutions, Inc
Location: Boise
Posted on: January 16, 2022

Job Description:

Utilization and Care Management Nurse Remote within WA, OR, ID, or UT. Candidates outside of these states will not be considered.At Cambia, our members need us more than ever, and to continue serving them, we need to be vaccinated. Following federal mandate, all Cambia Health Solutions employees, including 100% remote workers, need to be fully vaccinated for COVID-19 by 1/1/22. Are you a Registered Nurse that is passionate about making a difference? In this position, you would provide utilization management (such as prospective concurrent and retrospective review) integrated with clinical care management (such as case management, disease management, and/or care coordination) to best meet the member's special healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services. Oversees a collaborative process with the member and those involved in the member's care to assess, plan, implement, coordinate, monitor and evaluate care as needed. Responsibilities

  • Responsible for both prospective (Sometimes called "precertification review" or "prior authorization",) and concurrent review (Utilization management conducted during a patient's hospital stay or course of treatment, sometimes called "continued stay review") prior to and during a patient's admission and treatment in a variety of healthcare settings.
  • Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license.
  • Ability to initiate meaningful clinical dialogue with care providers/care recipients.
  • Consults with physician advisors to ensure clinically appropriate determinations.
  • Facilitates transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence's Case Management programs to achieve optimal recovery for the member.
  • Responsible for essential activities of case management including assessment, planning, implementation, coordination, monitoring and evaluation.
  • Serves as a resource to internal and external customers.
  • Collaborates with other departments to resolve claims, quality of care, member or provider issues.
  • Works with other departments collaboratively for the purpose of providing holistic care interventions to ensure that a patient's needs are being met.
  • Responds in writing, by phone or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues.
  • Provides consistent and accurate documentation.
  • Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines.Minimum Requirements
    • 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.
    • Strong oral, written and interpersonal communication skills.
    • Patient focused approach to problem solving, such as looking for opportunities to help each member achieve optimal health outcomes.
    • Strong customer service skills including listening, patience, empathy, maintaining confidentiality and focus on meeting customer needs.
    • Ability to interpret policies and procedures, make decisions, and communicate complex topics effectively.
    • Strong organization and time management skills with the ability to manage workload independently.
    • Ability to think critically and make decision within individual role and responsibility.Normally to be proficient in the competencies listed above:
      • Must have a current and unrestricted Registered Nurse (RN) license in WA, OR, UT, or ID, and at least 3 years (or full time equivalent) of direct clinical care.

Keywords: Cambia Health Solutions, Inc, Boise , Utilization and Care Management Nurse, Healthcare , Boise, Idaho

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