Remote Utilization Management RN for Quality & Cost

Arkansas Blue Cross Blue Shield; Heber (UT); A distancia; USD 80.000 - 110.000; Jornada completa

Descripción de la vacante

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries. You will evaluate inpatient and outpatient services for medical necessity using evidence-based criteria and collaborate with providers to promote cost-effective care.

The role requires an active RN license, a bachelor’s degree preferred, and at least four years of nursing practice in medical-surgical, ICU, or critical

Formación

• Minimum four (4) years' clinical practice nursing experience in medical-surgical, surgical, ICU or critical care.
• RN license active and in good standing in the relevant state(s).
• Bachelor's degree in Nursing preferred.

Responsabilidades

• Perform clinical review for prior approvals, network exceptions, and benefit inquiries.
• Assess medical necessity using evidence-based criteria and guidelines.
• Collaborate with providers and staff to promote appropriate care and cost containment.
• Document cases comprehensively and maintain compliance with URAC and state regulations.
• Work from home within specified states and travel as required.

Conocimientos

Interpersonal Relationship Management

Time Management

Educación

RN license (active in relevant jurisdiction)

Bachelor's degree in Nursing preferred

Herramientas

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Descripción del empleo

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and benefit inquiries. You will evaluate inpatient and outpatient services for medical necessity using evidence-based criteria and collaborate with providers to promote cost-effective care.

The role requires an active RN license, a bachelor’s degree preferred, and at least four years of nursing practice in medical-surgical, ICU, or critical