[Hiring] Clinical Specialist @Cambia Health Solutions

Role Description

Work from home within Idaho, Oregon, Utah, and Washington. Preference will be given to current employees and candidates who reside in Idaho or Utah.

Every day, Cambia’s dedicated team of Clinical Specialists is living our mission to make health care easier and lives better. As a member of the Clinical Operations team, our Clinical Specialists help us meet regulatory requirements as we insource prior authorization volume, support key initiatives, and ensure strong staffing coverage. By handling nonclinical tasks, they free up RNs to focus on clinical work and increase overall capacity – all in service of making our members’ health journeys easier.

Do you have strong organization and data management skills? Do you work effectively in a team environment? Then this role may be the perfect fit.

Qualifications

• High school diploma or equivalent and 2 years of clinical or hospital experience, or an equivalent combination of education and experience. LPN, CMA, or CNA preferred.
• Clinical experience, preferably in a hospital setting or a health plan clinical services setting.
• Strong and effective communication skills, both oral and written.
• Ability to work in a fast-paced environment while maintaining accuracy of work, confidentiality, and focus on meeting customer needs.
• Intermediate computer skills (e.g. Microsoft Office, Outlook, Internet search) and experience with health care systems and documentation (EMR, billing and claims).
• Demonstrated knowledge of medical terminology, anatomy, and coding (CPT, DX, HCPCs).
• Strong organization, data entry, and administrative skills.
• Ability to investigate and research complex issues and inquiries related to UM case work, use critical thinking skills, and work with clinical staff to resolve them.
• Ability to work independently, prioritize work, meet deadlines, and achieve operational standards.
• Ability to work effectively in a team environment.
• Ability to perform job duties and responsibilities for a UM Clinical Specialist.
• Ability to mentor and support co-workers and provide training to new team members.
• Experience with AI tools and technologies to enhance productivity and decision-making in professional settings highly desired.

Requirements

• Uses clinical knowledge and critical thinking to research simple to moderately complex requests and documentation related to utilization management (UM) processes and regulatory requirements.
• Reviews requests for completeness, obtains any missing information, and prepares cases for clinical review.
• Completes nonclinical case tasks, including documenting critical information, initiating referrals, and closing cases accurately.
• Conducts telephonic and written outreach to providers to request medical records and communicate case determinations, cancellations, and other information in compliance with regulatory and quality requirements.
• Manages time effectively and follows established guidelines to meet departmental standards for timeliness, production, quality, and accuracy, as well as federal, state, BCBSA, and accreditation requirements.
• Communicates effectively within and across teams, maintains organized access to reference materials, policies, and procedures, and upholds a professional, ethical, member-focused work environment.
• Supports continuous improvement by identifying workflow and system opportunities, and may assist with systems testing, coordinate case information in external vendor systems, or discuss service planning with providers.

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.