Utilization and Care Management Nurse

Working at Cambia means being part of a purpose-driven, award-winning culture built on trust and innovation anchored in our 100+ year history. Our caring and supportive colleagues are some of the best and brightest in the industry, innovating together toward sustainable, person-focused health care. Whether we're helping members, lending a hand to a colleague or volunteering in our communities, our compassion, empathy and team spirit always shine through.

Every day, Cambia’s dedicated team of Nurses are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Utilization and Care Management Nurses provide utilization and care management (such as prospective concurrent, retrospective review, post-discharge care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services – all in service of making our members’ health journeys easier. Are you a Nurse who has a passion for healthcare? Are you a Nurse who is ready to take your career to the next level and make a real difference in the lives of our members? Then this role may be the perfect fit.

Conducts utilization management reviews (prospective, concurrent, and retrospective) to ensure medical necessity and compliance with policy and standards of care. Participate in care management to identify and coordinate health care needs and gaps for members during the period of discharge from a facility until 30 days post discharge. Applies clinical expertise and evidence-based criteria to make determinations and consults with physician advisors as needed. Collaborates with interdisciplinary teams, case management, and other departments to facilitate transitions of care and resolve issues. Serves as a resource to internal and external customers, providing accurate and timely responses to inquiries. Identifies opportunities for improvement and participates in quality improvement efforts. Maintains accurate and consistent documentation and prioritizes assignments to meet performance standards and corporate goals. Protects confidentiality of sensitive documents and issues while communicating professionally with members, providers, and regulatory organizations.