Medical Care Management, RN

Arkansas Blue Cross Blue Shield; Provo (UT); Remote; USD 70,000 - 90,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an experienced Utilization Management Nurse (RN) to perform clinical reviews of prior approvals, network exceptions, and benefit inquiries. The role focuses on medical necessity, evidence-based care, and cost containment with a remote work option across multiple states.

The ideal candidate is an RN with 4+ years of clinical practice in medical-surgical, ICU, or critical care areas, licensed in the relevant jurisdiction, and with familiarity in

Qualifications

• Registered Nurse (RN) with active, current, unrestricted license in the state(s) where duties are performed.
• Bachelor's degree in Nursing preferred.
• Minimum four years of clinical practice nursing experience in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management and/or medical review preferred.
• Proficient with basic computer skills and MS Office (Word, Excel, Outlook).
• Ability to prioritize and make sound nursing judgments through critical thinking.

Responsibilities

• Conduct clinical review of prior approvals, network exceptions, and benefit inquiries.
• Assess medical necessity through evidence-based criteria and guidelines.
• Promote cost-effective and appropriate levels of care while ensuring patient safety.
• Collaborate with providers and internal staff to improve care quality and accessibility.
• Document clinical reviews and decisions accurately; adhere to policies and standards.
• Supports work from home setup and remote collaboration across states.

Skills

Data Analysis

Interpersonal Relationship Management

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Time Management

Collaboration with providers

Education

Bachelor's degree in Nursing

RN license

Tools

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Job description

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here .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.