Medical Care Management, RN

Arkansas Blue Cross Blue Shield; Arkansas; Remote; USD 85.000 - 120.000; Vollzeit

Zusammenfassung

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse who will perform clinical review of prior approvals, network exceptions, and benefit inquiries, ensuring medical necessity through evidence-based guidelines. The role requires a current RN license in good standing and typically four years of clinical practice in medical-surgical, surgical, ICU, or critical care.

You will work from home across Arkansas and several other states, using Microsoft Office tools to

Qualifikationen

• Active RN license in the relevant state(s) where duties are performed.
• Minimum four years of clinical practice nursing experience in medical-surgical, surgical, ICU, or critical care.
• Bachelor's degree in Nursing preferred.
• Experience with utilization management or medical review is a plus.
• Proficient in Microsoft Office and navigating multiple systems.

Aufgaben

• Perform clinical review of prior approvals, network exceptions, and benefit inquiries.
• Assess medical necessity and ensure appropriate level of care using evidence-based guidelines.
• Collaborate with providers and internal staff to promote quality and cost containment.
• Document findings and maintain compliance with URAC standards and state regulations.
• Work from home within specified states; prioritize nursing judgments and patient safety.

Kenntnisse

Interpersonal Relationship Management

Time Management

Ausbildung

Registered Nurse license in good standing

Bachelor's degree in Nursing preferred

Tools

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Jobbeschreibung

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.