Utilization Management - Inpatient to Transitions Clinical Specialist

Who We Are Looking For:

Every day, Cambia's dedicated team of Clinical Specialists are living to make health care easier and lives better. As a member of the Clinical team, our Clinical Specialists receive, research, and take action related to documentation and requests from a variety of sources related to Inpatient Utilization Management (UM) cases.

The UM Inpatient Clinical Specialist does not make clinical decisions, but partners with licensed health professionals and understands medical language and records. This helps UM nurses understand and take appropriate actions to support efficient and effective clinical reviews. All in service to 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.

Qualifications:

• High school diploma or equivalent
• Clinical experience is required
• At least 2 years of clinical experience preferred
• CMA or CNA preferred

• 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.

• 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

The expected hiring range for a UM IP Clinical Specialist is $25.90 - $37.30 an hour depending on location, skills, experience,…