Remote RN: Utilization Management & Care Optimization

Arkansas Blue Cross Blue Shield; United States; Remote; USD 80,000 - 120,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking an Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, benefit inquiries, and admissions. The role evaluates medical necessity using evidence-based criteria and company policies.

Required RN with active license and 4+ years of clinical practice in medical-surgical, surgical, ICU, or critical care. Work from home within several states; remote-friendly with cost containment focus.

Qualifications

• RN with active state license in good standing.
• Bachelor’s degree in Nursing preferred.
• Minimum four years’ clinical practice nursing experience in medical-surgical, surgical, ICU or critical care.

Responsibilities

• Collaborates with healthcare providers and staff to promote quality of care and cost effectiveness.
• Performs clinical reviews to ensure medical necessity of inpatient/outpatient services.
• Adheres to URAC standards, state regulations and company policies.
• Maintains current knowledge of procedures, products and contracts.

Skills

Active Listening

Analytical Decision Making

Critical Thinking

Data Analysis

Educational Development

Interpersonal Relationship Management

Oral Communications

Problem Sensitivity

Sound Judgment

Team Development

Time Management

Written Communication

Education

Bachelor’s degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

Job description

Arkansas Blue Cross Blue Shield is seeking an Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, benefit inquiries, and admissions. The role evaluates medical necessity using evidence-based criteria and company policies.

Required RN with active license and 4+ years of clinical practice in medical-surgical, surgical, ICU, or critical care. Work from home within several states; remote-friendly with cost containment focus.