Remote RN Utilization & Medical Necessity Reviewer

Arkansas Blue Cross and Blue Shield; United States; On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Tuition reimbursement

Club Blue onsite gym

Green Leaf Grill onsite restaurants

Wellness education incentives

Job summary

Arkansas Blue Cross and Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews of prior approvals, network exceptions, benefit inquiries, inpatient surgical and outpatient procedures to assess medical necessity. You will interpret evidence-based criteria and corporate guidelines to support appropriate care.

The role emphasizes collaboration with providers, documentation of decisions, and adherence to regulatory standards while promoting safe,

Qualifications

• Bachelor's degree in nursing preferred.
• RN with active, unrestricted license in the relevant jurisdiction.
• Minimum four years of clinical nursing in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management or medical review preferred.
• Proficient in Microsoft Office and able to navigate multiple systems.

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 and documents findings.
• Performs duties while adhering to URAC standards, state regulations and safety requirements.
• Promotes cost containment and evidence-based practice through ongoing evaluation.

Skills

Oral & Written Communication

Attention to Detail

MS Office proficiency

Critical Thinking

Collaboration

Documentation interpretation

Independent work

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 experienced Utilization Management Nurse to perform clinical reviews of prior approvals, network exceptions, benefit inquiries, inpatient surgical and outpatient procedures to assess medical necessity. You will interpret evidence-based criteria and corporate guidelines to support appropriate care.

The role emphasizes collaboration with providers, documentation of decisions, and adherence to regulatory standards while promoting safe,