Remote RN: Utilization Management & Care Quality

Arkansas Blue Cross Blue Shield; Oregon; Hybrid; USD 80,000 - 105,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking a licensed RN to perform clinical review of prior approvals, network exceptions, and medical necessity determinations for inpatient and outpatient services. You will interpret criteria and collaborate with providers to promote quality care and cost containment.

The role enables remote work from home across several states, requiring strong communication, critical thinking, and ability to navigate multiple systems while maintaining compliance with URAC

Qualifications

• RN license in good standing in relevant state(s).
• Bachelor's degree in Nursing preferred.
• Minimum four years of clinical nursing experience in medical-surgical, ICU, or critical care.

Responsibilities

• Promotes quality of care and cost effectiveness through clinical review.
• Perform clinical review of inpatient/outpatient cases to ensure medical necessity.
• Document determinations and prioritize requests according to standards.
• Adhere to URAC standards and state regulations; ensure patient safety.
• Maintain current knowledge of procedures, policies, contracts.

Skills

Oral & Written Communication

Attention to Detail

Critical Thinking

Team Collaboration

Independent Work

Prioritization

Education

Bachelor's degree in Nursing

RN license (active) in good standing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Job description

Arkansas Blue Cross Blue Shield is seeking a licensed RN to perform clinical review of prior approvals, network exceptions, and medical necessity determinations for inpatient and outpatient services. You will interpret criteria and collaborate with providers to promote quality care and cost containment.

The role enables remote work from home across several states, requiring strong communication, critical thinking, and ability to navigate multiple systems while maintaining compliance with URAC