Remote RN Utilization Management Nurse — Quality, Cost & Care

Arkansas Blue Cross and Blue Shield; Arkansas; Remote; USD 66,000 - 84,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries from a home office in Arkansas or other eligible states. The role focuses on medical necessity and evidence-based criteria to guide cost-effective care.

Candidates should have an RN license in good standing, a Bachelor's degree in Nursing preferred, and at least four years of clinical nursing experience with utilization

Qualifications

• Bachelor's degree in nursing preferred.
• Active, unrestricted RN license in relevant jurisdictions.
• Minimum four years of clinical nursing experience in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management and/or medical review preferred.

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; documenting all relevant and specific information; screens, prioritizes and organizes determination requests according to mandates and standards.
• Performs other duties as assigned.
• Practices nursing within the scope of licensure and adheres to policies, regulations, URAC standards and state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Skills

RN license

Nursing degree

Clinical nursing

Utilization management

Medical review

Critical thinking

Communication

Documentation

Teamwork

Microsoft Office

Education

Bachelor's degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

Job description

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries from a home office in Arkansas or other eligible states. The role focuses on medical necessity and evidence-based criteria to guide cost-effective care.

Candidates should have an RN license in good standing, a Bachelor's degree in Nursing preferred, and at least four years of clinical nursing experience with utilization