Medical Care Management, RN

Arkansas Blue Cross Blue Shield; Eagle (ID); Remote; USD 85,000 - 115,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking a qualified Utilization Management Nurse to perform clinical review of prior approvals, network exceptions, and benefit inquiries. You will assess medical necessity and promote quality care while controlling costs using evidence-based guidelines and corporate policies.

The role requires an active RN license, a Bachelor's degree preferred, and at least four years of clinical nursing experience in med-surg, ICU, or critical care.

Qualifications

• Bachelor's degree in Nursing preferred.
• RN license active in the relevant state(s) required.
• Minimum four years of clinical nursing in med-surg, ICU, or critical care.
• Utilization management/medical review experience preferred.
• Proficiency with basic Microsoft Office and multi-system navigation.

Responsibilities

• Perform clinical review of prior approvals, network exceptions, benefit inquiries.
• Assess and evaluate medical necessity using evidence-based criteria and guidelines.
• Collaborate with providers and internal staff to promote quality and cost effective care.
• Document review cases and maintain compliance with URAC and state regulations.
• Promote cost containment and appropriate levels of care while ensuring patient safety.

Skills

Interpersonal Relationship Management

Time Management

Critical Thinking

Prioritization

Education

Registered Nurse license

Bachelor's degree in Nursing preferred

Tools

Microsoft Outlook

Microsoft Word

Microsoft SharePoint

Microsoft Excel

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.