Remote RN: Utilization Management & Care Optimization

Arkansas Blue Cross and Blue Shield; Little Rock (AR); Remote; USD 66,000 - 84,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries. The role evaluates medical necessity using evidence-based criteria and contributes to cost containment and quality of care.

The position requires a RN license in good standing, a BSN preferred, and at least four years of clinical nursing experience in medical-surgical, ICU, or related areas.

Qualifications

• Bachelor's degree in Nursing is preferred.
• Registered Nurse (RN) license active in the relevant jurisdiction(s).
• Minimum four years of clinical nursing experience in medical-surgical, surgical, ICU or critical care.

Responsibilities

• 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; documents all relevant information and prioritizes requests.
• Performs other duties as assigned.
• Practices nursing within licensure scope and adheres to policies, procedures, URAC standards and state regulations; makes decisions based on facts and evidence.
• Promotes evidence-based care to support cost containment and quality.

Skills

Active Listening

Analytical Decision Making

Critical Thinking

Data Analysis

Educational Development

Interpersonal Relationship Management

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Oral Communications

Problem Sensitivity

Sound Judgment

Team Development

Time Management

Written Communication

Education

Bachelor's degree in Nursing

Job description

Arkansas Blue Cross and Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries. The role evaluates medical necessity using evidence-based criteria and contributes to cost containment and quality of care.

The position requires a RN license in good standing, a BSN preferred, and at least four years of clinical nursing experience in medical-surgical, ICU, or related areas.