Remote Utilization Management Nurse | Care Coordination

Blue Cross and Blue Shield of Nebraska; Nebraska; On-site; USD 85,000 - 105,000; Full time

Job summary

Blue Cross and Blue Shield of Nebraska is seeking an experienced nurse to review medical necessity and coordinate care across inpatient and outpatient settings. You will educate providers on benefits, facilitate timely transitions of care, and refer complex cases to care management teams.

The role requires an active RN license, 3+ years of clinical practice, and experience with Medicare/Commercial Insurance or Managed Care.

Qualifications

• Associate’s degree in nursing completed and active RN license.
• Three years of clinical practice in a healthcare setting.
• Experience with Medicare/Commercial Insurance or Managed Care.
• Discharge planning, utilization management or case management experience.
• Ability to work rotating weekend/holiday shifts as needed.

Responsibilities

• Review medical necessity for inpatient and outpatient services and determine appropriate setting using policy and criteria.
• Educate providers about member benefits, coverage, networks and utilization processes.
• Coordinate transitions of care and discharge planning with providers for the proper level of care.
• Identify members for care management and refer to care coordination teams.
• Collaborate with physicians, nurses, medical directors and pharmacists to deliver high‑quality, cost‑effective care.
• Attend weekly rounds to discuss high‑cost cases and discharge planning concerns.
• Serve as a department resource on medical management and regulatory compliance.
• Maintain compliance with Medicare Advantage, URAC standards, and related regulations.

Skills

RN license

Discharge planning

Utilization management

Case management

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 nurse to review medical necessity and coordinate care across inpatient and outpatient settings. You will educate providers on benefits, facilitate timely transitions of care, and refer complex cases to care management teams.

The role requires an active RN license, 3+ years of clinical practice, and experience with Medicare/Commercial Insurance or Managed Care.