Medical Care Management, RN

Arkansas Blue Cross Blue Shield; Accident (AR); Remote; USD 85,000 - 110,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews of prior approvals, network exceptions, and inpatient/outpatient procedures. The role ensures medical necessity and cost-effective care through adherence to guidelines and policies.

The ideal candidate holds an active RN license, a BSN preferred, and at least four years of clinical practice in medical-surgical, ICU, or related areas.

Qualifications

• Registered Nurse with active, current license in the relevant jurisdiction.
• BSN preferred and at least 4 years of clinical nursing experience.
• Experience in utilization management or medical review is preferred.
• Proficiency with Microsoft Office and navigating multiple systems.

Responsibilities

• Conduct clinical review of prior approvals, network exceptions, benefit inquiries, and admissions.
• Assess medical necessity using evidence-based criteria, guidelines and policies.
• Promote cost containment and appropriate care through informed decisions.
• Collaborate with providers and internal staff to ensure quality of care.

Skills

Nursing

Critical Thinking

Clinical Review

Education

Bachelor's degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

Job description

Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence. Bachelor's degree in Nursing preferred.

Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required.

Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.

Experience in utilization management and/or medical review preferred.

Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding.

Ability to prioritize and make sound nursing judgments through critical thinking.

Work from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota.

Data Analysis

• Interpersonal Relationship Management
• Microsoft Outlook
• Microsoft SharePoint
• Microsoft Word
• Time Management

Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.

Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.

Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.

This position is identified as level three (3). The integrity of information must be maintained as outlined in the company Administrative Manual.

This position must adhere to the segregation of duties guidelines in the Administrative Manual.

2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.