Remote RN: Utilization Management & Medical Review

Arkansas Blue Cross and Blue Shield; Arkansas; Hybrid; USD 70,000 - 100,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to perform clinical review of prior approvals, network exceptions, benefit inquiries, inpatient admissions and outpatient procedures. The role evaluates medical necessity using evidence-based criteria and promotes cost containment through informed decision making.

The candidate should hold a Bachelor's degree in Nursing and an active RN license, with at least four years of clinical nursing experience in relevant

Qualifications

• Bachelor's degree in Nursing; RN licensure in relevant jurisdiction.
• Four+ years of clinical nursing experience in medical-surgical, surgical, ICU/critical care or related areas; utilization management experience preferred.

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care and cost effectiveness.
• Conducts and monitors clinical reviews to ensure medical necessity for inpatient and outpatient services; documents findings.
• Performs duties within licensure scope and adheres to policies, procedures, URAC standards and state regulations.
• Promotes appropriate care and cost containment based on evidence; stays current with medical procedures and contracts.
• Handles incoming/outbound calls and queues from multiple sources within mandated requirements.

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

Registered Nurse License

Tools

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Excel

Job description

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to perform clinical review of prior approvals, network exceptions, benefit inquiries, inpatient admissions and outpatient procedures. The role evaluates medical necessity using evidence-based criteria and promotes cost containment through informed decision making.

The candidate should hold a Bachelor's degree in Nursing and an active RN license, with at least four years of clinical nursing experience in relevant