Remote Care Management Nurse

About the role

Every day, Cambia’s dedicated team of Care Management RNs are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our Care Management RNs provide clinical care management (such as case management, disease management, and/or care coordination) to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes. 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 – all in service of creating a person-focused health care experience. This role is part of our candidate pool for future opportunities; by submitting your resume, you will be included in our database and considered for suitable positions as they become available.

What You Will Do

• Conducts case management activities, including assessment, planning, implementation, coordination, monitoring, and evaluation to identify and meet member needs
• Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care, utilizing evidence-based criteria and practicing within the scope of their license
• Collaborates with physician advisors, internal and external customers, and other departments to resolve claims, quality of care, member or provider issues, and identifies problems or needed changes, recommending resolutions and participating in quality improvement efforts
• Serves as a resource to internal and external customers, responding to inquiries in a professional manner while protecting confidentiality of sensitive documents and issues
• Provides consistent and accurate documentation, ensuring compliance with performance standards, corporate goals, and established timelines
• Coordinates resources, organizes, and prioritizes assignments to meet goals and timelines
• Monitors and evaluates the effectiveness of case management plans, gathering sufficient information to determine the plan's effectiveness and making adjustments as needed

Qualifications

• Nursing or health/human services degree (Associate's or Bachelor's minimum), or equivalent experience in lieu of a degree
• Minimum 3 years of direct clinical care or experience in case management, utilization management, disease management, auditing, or retrospective review
• Active, unrestricted licensure or certification in a U.S. state or territory that allows you to independently conduct assessments within your scope of practice — RN license required for medical care management
• Must be eligible for licensure in Idaho, Oregon, Utah, and Washington

Skills

• 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 and customer service skills
• 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
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired

Pay

Oregon, Washington, Utah, and Idaho: expected hiring range $36.80 – $49.80 an hour, full salary range $34.20 – $55.70 an hour, bonus target 10%. North Dakota: expected hiring range $35.21 – $47.63 an hour, full salary range $31.86 – $50.98 an hour.

Benefits

• Medical, dental and vision coverage for employees and their eligible family members, including mental health benefits
• Annual employer contribution to a health savings account
• Generous paid time off varying by role and tenure in addition to 10 company-paid holidays
• Market-leading retirement plan including a company match on employee 401(k) contributions, with a potential discretionary contribution based on company performance (no vesting period)
• Up to 12 weeks of paid parental time off (eligibility requires 12 months of continuous service with Cambia immediately preceding leave)
• Award-winning wellness programs that reward you for participation
• Employee Assistance Fund for those in need
• Commute and parking benefits

Schedule

Work from home within Oregon, Washington, Idaho or Utah (also open to current BCBSND employees). Requires wired internet connection (not satellite or cellular) with minimum upload speed of 5Mb and minimum download speed of 10 Mb. New hires need access to a personal mobile device for Multi-Factor Authentication setup.