Remote RN: Utilization Management & Clinical Review

Arkansas Blue Cross Blue Shield; Bismarck (ND); Teletrabalho; USD 70 000 - 110 000; Tempo integral

Resumo da oferta

Arkansas Blue Cross Blue Shield is seeking a Utilization Management Nurse who evaluates prior approvals, network exceptions, and benefit inquiries to ensure medical necessity in line with evidence-based guidelines. The role supports cost containment and quality care while coordinating with providers and internal staff.

Qualified candidates hold a current RN license in the relevant states and have at least four years of clinical nursing experience in medical-surgical, surgical, ICU, or critical

Qualificações

• Bachelor's degree in Nursing preferred.
• Active RN license in the relevant state(s) with good standing.
• Minimum four years of clinical nursing experience in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management and/or medical review preferred.
• Proficient in MS Office (Word, Excel, Outlook) and able to navigate multiple systems.
• Ability to prioritize and exercise sound nursing judgment.

Responsabilidades

• Conduct clinical review of prior approvals, network exceptions, benefit inquiries, inpatient/outpatient procedures.
• Interpret and apply evidence-based criteria and corporate guidelines to determine medical necessity.
• Promote cost effectiveness and appropriate levels of care.
• Stay current with medical procedures, products, services and enterprise policies.

Conhecimentos

Interpersonal Relationship Management

Time Management

Data Analysis

Formação académica

RN license in relevant state(s)

Bachelor's degree in Nursing preferred

Ferramentas

Microsoft Outlook

Microsoft Word

Microsoft Excel

Microsoft SharePoint

Descrição da oferta de emprego

Arkansas Blue Cross Blue Shield is seeking a Utilization Management Nurse who evaluates prior approvals, network exceptions, and benefit inquiries to ensure medical necessity in line with evidence-based guidelines. The role supports cost containment and quality care while coordinating with providers and internal staff.

Qualified candidates hold a current RN license in the relevant states and have at least four years of clinical nursing experience in medical-surgical, surgical, ICU, or critical