Utilization Management - Inpatient Clinical Specialist

Utilization Management Inpatient Clinical Specialist Work from home within Washington, Oregon, Idaho or Utah Preference will be given to current employees and candidates who reside in Idaho and Utah Build a career with purpose. Join our Cause to create a person-focused and economically sustainable health care system.

Every day, Cambia’s dedicated team of Utilization Management Inpatient (UM IP) Clinical Specialist are living our mission to make health care easier and lives better. As a member of the Clinical Services team, our UM 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.

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…