Washington, DC · Remote
$25.90 - $37.30/hr
You'll utilize clinical knowledge and critical thinking to research and review IP UM requests ... for all work. #LI-Remote Pay ranges vary based on the candidate's work location. The expected ...
Washington, DC · Remote
$25.90 - $37.30/hr
You'll utilize clinical knowledge and critical thinking to research and review IP UM requests ... for all work. #LI-Remote Pay ranges vary based on the candidate's work location. The expected ...
Austin, TX; Remote This is a rare opportunity to step into a high-impact leadership role at the ... Utilization Review & Authorizations * Oversee authorization strategy and utilization review ...
Austin, TX; Remote This is a rare opportunity to step into a high-impact leadership role at the ... Utilization Review & Authorizations * Oversee authorization strategy and utilization review ...
Austin, TX; Remote This is a rare opportunity to step into a high-impact leadership role at the ... Utilization Review & Authorizations * Oversee authorization strategy and utilization review ...
Austin, TX; Remote This is a rare opportunity to step into a high-impact leadership role at the ... Utilization Review & Authorizations * Oversee authorization strategy and utilization review ...
Millersville, MD · On-site +1
$189K - $238K/yr
Remote Type: Part-Time *This position is contingent upon the successful award of the associated ... Minimum Requirements: * 10+ years clinical practice; experience in peer review, utilization review ...
Millersville, MD · On-site +1
$189K - $238K/yr
Remote Type: Part-Time *This position is contingent upon the successful award of the associated ... Minimum Requirements: * 10+ years clinical practice; experience in peer review, utilization review ...
Silver Spring, MD · Remote
$60 - $72.25/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Silver Spring, MD · Remote
$60 - $72.25/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Pasadena, MD · Remote
$59.25 - $71/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Pasadena, MD · Remote
$59.25 - $71/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Ashburn, VA · Remote
$59.50 - $71.50/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Ashburn, VA · Remote
$59.50 - $71.50/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Annandale, VA · Remote
$58 - $69.50/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Annandale, VA · Remote
$58 - $69.50/hr
Review prior authorization requests for accuracy, appropriateness, and clinical necessity. * Apply ... Prior authorization, utilization management, or managed care preferred - retail or hospital ...
Reston, VA · On-site +1
Oversee project budgets and staffing utilization. * Review monthly financial reports and support ... Experience managing remote or distributed teams. * Excellent written and verbal communication ...
Reston, VA · On-site +1
Oversee project budgets and staffing utilization. * Review monthly financial reports and support ... Experience managing remote or distributed teams. * Excellent written and verbal communication ...
Ashburn, VA · On-site +1
$58.50 - $71.25/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Ashburn, VA · On-site +1
$58.50 - $71.25/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Silver Spring, MD · On-site +1
$59 - $72/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Silver Spring, MD · On-site +1
$59 - $72/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Annandale, VA · On-site +1
$57 - $69.50/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Annandale, VA · On-site +1
$57 - $69.50/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Pasadena, MD · On-site +1
$58.25 - $70.75/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Pasadena, MD · On-site +1
$58.25 - $70.75/hr
Review clinical documentation for medication coverage appeals and grievances. * Apply evidence ... Prior managed care or utilization management experience preferred - retail and hospital pharmacists ...
Annapolis, MD · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
Annapolis, MD · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
Washington, DC · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
Washington, DC · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
Annapolis, MD · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
Annapolis, MD · Remote
$54K - $155K/yr
Position Summary This is a remote work from home role anywhere in the US with virtual training ... Utilization Review. * CCM and/or other URAC recognized accreditation preferred. * 1+ years ...
... and utilization review. • Secure contracts and agreements, where necessary or optimal, to ... remote and in-person, and manage follow-up. • Collaborate with Customer Success to onboard new ...
Quick apply
... and utilization review. • Secure contracts and agreements, where necessary or optimal, to ... remote and in-person, and manage follow-up. • Collaborate with Customer Success to onboard new ...
Annapolis, MD · On-site +1
$85K/yr
Care Management / Utilization Management Salary: $85,000 Position Summary A managed care ... Review clinical documentation and assessments to determine appropriate placement based on member ...
Annapolis, MD · On-site +1
$85K/yr
Care Management / Utilization Management Salary: $85,000 Position Summary A managed care ... Review clinical documentation and assessments to determine appropriate placement based on member ...
We go beyond merely providing a remote work option; we support and embrace it. We offer ... Prior utilization management, peer review, or appeals experience (helpful but not required). Equal ...
We go beyond merely providing a remote work option; we support and embrace it. We offer ... Prior utilization management, peer review, or appeals experience (helpful but not required). Equal ...
Clinton, MD · Remote
$2.0K - $2.8K/mo
Train, mentor, and evaluate team performance of 3 remote bookkeepers 2. Bookkeeping Operations ... Review: * Profit & Loss statements * Balance sheets * General ledger activity * Ensure timely ...
Quick apply
Clinton, MD · Remote
$2.0K - $2.8K/mo
Train, mentor, and evaluate team performance of 3 remote bookkeepers 2. Bookkeeping Operations ... Review: * Profit & Loss statements * Balance sheets * General ledger activity * Ensure timely ...
$24.23 - $29.13
2% of jobs
$29.13 - $34.03
9% of jobs
$37.39 is the 25th percentile. Wages below this are outliers.
$34.03 - $38.93
21% of jobs
The median wage is $42.90 / hr.
$38.93 - $43.83
23% of jobs
$43.83 - $48.73
13% of jobs
$52.55 is the 75th percentile. Wages above this are outliers.
$48.73 - $53.63
10% of jobs
$53.63 - $58.54
8% of jobs
$58.54 - $63.44
5% of jobs
$63.44 - $68.34
5% of jobs
$68.34 - $73.24
2% of jobs
$73.24 - $78.14
2% of jobs
$24
$47
$78
To thrive as a Remote Utilization Review professional, you need a solid foundation in clinical knowledge, critical thinking, and an active RN or LPN license, often supported by experience in case management or prior authorization. Familiarity with medical coding (ICD-10, CPT), electronic health records (EHRs), and utilization management software is typically required, along with URAC or related certifications. Excellent communication, attention to detail, and strong organizational skills help you efficiently manage cases and coordinate with providers and payers. These skills ensure accurate assessments of medical necessity, compliance with regulations, and effective remote collaboration with healthcare teams.
A typical day for a Remote Utilization Review professional involves reviewing patient medical records, evaluating the necessity of proposed treatments against established guidelines, and collaborating with healthcare providers to gather additional information when needed. You will spend much of your time analyzing documentation, submitting recommendations, and ensuring that care authorization decisions align with payer policies and clinical best practices. Communication with case managers, physicians, and insurance representatives is frequent and essential. The work is generally independent and deadline-driven but requires strong teamwork and responsiveness through virtual meetings, emails, and calls.
A Remote Utilization Review job involves assessing medical records and treatment plans to ensure they meet insurance guidelines and medical necessity criteria. Professionals in this role, often nurses or healthcare specialists, work remotely to review patient care for cost-effectiveness and compliance with policies. They collaborate with healthcare providers, insurance companies, and case managers to approve or deny services based on established guidelines. This position requires strong analytical skills, knowledge of medical policies, and attention to detail.
$25.90 - $37.30/hr
Full-time
Medical, Dental, Vision, Retirement, PTO
This job post has expired today. Applications are no longer accepted.
8.4
Based on 31 frontline employees who took The Breakroom Quiz
101st of 261 rated insurance
Every day, Cambia's dedicated team ofUtilization Management Inpatient (UM IP) Clinical Specialistare living our mission to make health care easier and lives better. As a member of theClinical Servicesteam, ourUM IP Clinical Specialist receives, researches, and takes action related to documentation and requests from a variety of sources related to Inpatient Utilization Management cases. The UM IP Clinical Specialist does not make clinical decisions, but partners with licensed health professionals on appropriate actions and responses to support efficient and effective clinical reviews - all in service of making our members' health journeys easier.
Are you someone who has strong clinical experience and passion for healthcare? Are you 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.
What You Bring to Cambia:Qualifications:
High school diploma or equivalent
Clinical experience is required
At least 2 years of clinical experience preferred
CMA or CNA preferred
Skills and Attributes:
Clinical experience, preferably in the inpatient hospital setting, strong communication skills, both oral and written, to effectively interact with other clinical staff.
Computer skills, including Microsoft Office, Outlook, internet search. As well as experience with healthcare systems and documentation, EMRs, billing, and claims, with a preference for significant prior experience navigating and documenting in an EMR.
Knowledge of medical terminology, anatomy, and coding, including CPT, DX, and HCPCs. Applying this knowledge to investigate and research complex issues and inquiries related to Inpatient Utilization Management case work, using critical thinking skills and collaborating with clinical staff to resolve them.
You'll work independently with a high volume case load, prioritizing tasks, meeting deadlines, and achieving operational standards, while also being able to work effectively in a team environment while being able to adapt to changes in the healthcare insurance industry.
You'll perform job duties and responsibilities for an UM IP Clinical Specialist, utilizing strong organization, data entry, and administrative skills to ensure accurate and efficient work, while maintaining confidentiality and focus on meeting customer needs in a fast-paced environment.
What You Will Do at Cambia:
You'll utilize clinical knowledge and critical thinking to research and review IP UM requests, ensuring completeness of information and taking action to obtain necessary details, while also completing non-clinical tasks to close cases accurately and efficiently.
You'll communicate effectively with internal and external stakeholders, including providers and team members, to accomplish role functions and facilitate written notifications in compliance with regulatory and quality entities.
You'll exhibit excellent time management skills to ensure timeliness of UM activities, meeting regulatory and quality requirements, and follow strict guidelines to ensure all work meets corporate standards for accuracy, timeliness, quality, and compliance with federal, state, BCBSA, and accreditation regulations.
You'll organize and maintain reference documents, policies, and procedures, and demonstrate a professional and ethical work environment, promoting a positive and respectful atmosphere with both internal and external stakeholders.
You'll perform detailed research and problem-solve using sound decision-making skills to ensure IP UM case accuracy and completeness, and contribute to continuous improvement by identifying opportunities for improvement within systems and workflows.
Initiate referrals to adjacent teams as needed.
You'll discuss discharge planning with providers as needed, and may assist with systems testing, while adhering to accountability, member focus, and all performance criteria established by the department, including timeliness, production, and quality standards for all work.
#LI-Remote
Pay ranges vary based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history.
Oregon, Washington, Utah, and Idaho:The expected hiring range is$25.90 - $37.30anhourand the full salary range is$24.40 - $42.20an hour.
The bonus target for this position is5%.
About Cambia
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.
Why Join the Cambia Team?
At Cambia, you can:
We believe a career at Cambia is more than just a paycheck - and your compensation should be too. Our compensation package includes competitive base pay as well as a market-leading 401(k) with a significant company match, bonus opportunities and more.
In exchange for helping members live healthy lives, we offer benefits that empower you to do the same. Just a few highlights include:
Learn more about our benefits.
We are happy to offer work from home options for most of our roles. To take advantage of this flexible option, we require employees to have a wired internet connection that is not satellite or cellular and internet service with a minimum upload speed of 5Mb and a minimum download speed of 10 Mb.
We are an Equal Opportunity employer dedicated to a drug and tobacco-free workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, religion, age, sex, sexual orientation, gender identity, disability, protected veteran status or any other status protected by law. A background check is required.
If you need accommodation for any part of the application process because of a medical condition or disability, please email CambiaCareers@cambiahealth.com. Information about how Cambia Health Solutions collects, uses, and discloses information is available in our Privacy Policy.
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Sourced by ZipRecruiter
Health care and social assistance
1,001 - 5,000 Employees
Portland, OR, US
1996
