Remote RN: Utilization Management & Care Optimization

Arkansas Blue Cross and Blue Shield; United States; Hybrid; USD 80,000 - 110,000; 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 medical necessity. The role evaluates inpatient and outpatient services against evidence-based criteria and corporate policies.

The ideal candidate holds an RN license, 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 (preferred) and RN license in good standing.

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.
• Practices nursing within scope of licensure and adheres to URAC standards and state regulations; making decisions based on facts and evidence.
• Promotes cost containment and quality improvements based on evidence and guidelines.

Skills

Oral communication

Written communication

Attention to detail

Critical thinking

Data analysis

Time management

Interpersonal skills

Team development

Sound judgment

Education

Bachelor's degree in Nursing

RN license (active)

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

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 medical necessity. The role evaluates inpatient and outpatient services against evidence-based criteria and corporate policies.

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