Remote Utilization Management Nurse - Care Coordination

Blue Cross Blue Shield of Nebraska; Nebraska; Hybrid; USD 65,000 - 90,000; Full time

Job summary

Blue Cross and Blue Shield of Nebraska is seeking an experienced registered nurse to conduct clinical claim reviews and authorize appropriate care levels. The role collaborates with providers, medical directors and pharmacists to ensure medically necessary care and optimal outcomes for members.

The position emphasizes discharge planning, transitions of care, and ongoing utilization management in a remote setting accessible to nurses in listed states.

Qualifications

• Associate's degree in nursing required.
• Active nursing license Nebraska or consortium state.
• Experience in Medicare/Commercial Insurance, Medicare Advantage, or Managed Care preferred.
• Experience in discharge planning, utilization management, case management, or disease management.
• Ability to work rotating weekend/holiday shifts as needed.

Responsibilities

• Conduct clinical claim certification and authorization reviews for medical necessity.
• Educate providers about member benefits, coverage, and networks.
• Coordinate transitions of care and discharge planning.
• Collaborate with healthcare providers and internal teams to ensure high-quality, cost-effective care.
• Meet compliance requirements and maintain licensure.

Skills

Clinical nursing

Discharge planning

Utilization management

Case management

Disease management

Team collaboration

Weekend/holiday shift flexibility

Education

Associate's degree in nursing

Bachelor's degree in healthcare field

Job description

Blue Cross and Blue Shield of Nebraska is seeking an experienced registered nurse to conduct clinical claim reviews and authorize appropriate care levels. The role collaborates with providers, medical directors and pharmacists to ensure medically necessary care and optimal outcomes for members.

The position emphasizes discharge planning, transitions of care, and ongoing utilization management in a remote setting accessible to nurses in listed states.