Supervisor Utilization Management

About the role

Cambia is seeking a Supervisor Utilization Management to join our team. This role is hybrid (3 days/week in office), with candidates required to reside within commutable distance of one of our offices in Burlington, Renton, Spokane, Vancouver, Portland, Medford, Salt Lake City, Boise, Lewiston, or Fargo. Candidates must have a Bachelor's degree in Nursing or a related field, 5 years of clinical experience, and a current RN license. The role involves leading a team in managing utilization management programs and ensuring compliance with medical policies.

Responsibilities

• Assigns and prioritizes work, sets goals, and coordinates daily activities of the team.
• Provides regular updates and communication to staff through 1:1 and team meetings.
• Makes sure individual and team results are completed in a timely manner, in accordance with department standards and procedures, and are in compliance with medical policy and medical necessity guidelines.
• Aids in developing productivity and quality standards.
• Conducts or participates in compliance audits and reports audit findings.
• Identifies and implements process improvements as needed.
• Acts as a resource for staff and others.
• Escalates issues and partners with other departments to resolve issues and remove barriers.
• Collaborates with physician advisors on complex case and coverage determination processes.
• Participates in the hiring process, provides on-going coaching, employee development, and writing of performance reviews.
• Maintains clinical competency and keeps current on medical practices, procedures, and industry trends.
• Develops and maintains desk reference guides on work procedures.
• Ensures new hires complete necessary training.
• Assesses training needs and plays an active role in development of staff.
• Completes special projects as assigned and may provide back-up support to staff as needed.
• Maintains clinical competency and keeps current on medical practices, procedures, and industry trends.
• May develop and present educational updates internally or to other departments.
• Sets and achieves goals for personal and team growth.
• Seeks ideas and opportunities for continuous improvement, determines which opportunities should be pursued and implements improvements as appropriate.

Requirements

• Bachelor's degree in Nursing or related field.
• 3 years of leadership experience.
• 5 years of clinical experience or equivalent combination of education and experience.
• License or certification in a state or territory of the United States in the health or human services-related field that allows the professional to conduct an assessment as permitted within the scope of practice of the discipline (e.g. medical vs. behavioral health).
• Current unrestricted Registered Nurse (RN) license in a state or territory of the United States.

Skills and Attributes

• Demonstrated competency in setting priorities for a team and overseeing work outputs and timelines.
• Ability to communicate effectively, verbally and in writing including with members, employer or provider groups.
• Ability to effectively develop and lead a team (including employees who may be in multiple locations or work remotely).
• Demonstrated experience in recognizing problems and effectively resolving complex issues.
• Familiarity with health insurance industry trends and technology.
• Demonstrated competency related to clinical utilization management and care management practices.
• Knowledge of payment coding guidelines, as applicable (Payment Review only).
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Pay

The pay range varies based on the candidate's work location. The expected hiring range depends on skills, experience, education, and training; relevant licensure / certifications; and performance history. For example, in Oregon, Washington, Utah, and Idaho, the expected hiring range is $92,700 - $125,400, the full salary range is $87,000 - $142,000, and the bonus target is 15%. In North Dakota, the expected hiring range is $90,906.65 - $122,991.35 and the full salary range is $80,717 - $133,182.

About Cambia

Cambia is a purpose-driven organization dedicated to creating a person-focused and economically sustainable health care system. We believe in making health care easier and lives better every day. Our team of Utilization Management (UM) Leaders and Clinical Services leaders work tirelessly to ensure that our members receive the care they need, in a way that is both medically necessary and cost-effective. We are committed to fostering a culture of learning and growth, where our team members can continually improve their skills and contribute to our mission.