Remote Utilization Management RN – Medical Review & Care Optimization

Arkansas Blue Cross Blue Shield; Utah; Remote; USD 85,000 - 110,000; Full time

Job summary

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and various inpatient/outpatient cases. This role ensures medical necessity aligns with evidence-based guidelines and corporate policies.

The RN must hold an active license, have 4+ years of clinical nursing practice, and be capable of remote work from several western states while maintaining compliance and cost containment goals.

Qualifications

• RN with active, current, unrestricted license in the relevant jurisdiction.
• Bachelor's degree in Nursing preferred.
• Minimum four (4) years of clinical practice nursing experience in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management and/or medical review preferred.
• Proficient with basic Microsoft Office and ability to navigate multiple systems.

Responsibilities

• Conduct clinical review of prior approvals, network exceptions, benefit inquiries, and inpatient/outpatient services to ensure medical necessity.
• Collaborate with healthcare providers and internal staff to promote quality, cost effectiveness, accessibility and appropriate service levels.
• Document all relevant information and adhere to URAC standards and state regulations.
• Promote appropriate care and cost containment based on evidence and corporate guidelines.

Skills

Interpersonal Relationship Management

Critical thinking

Time management

Prioritization

Education

Bachelor's degree in Nursing

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Microsoft SharePoint

Job description

Arkansas Blue Cross Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews for prior approvals, network exceptions, and various inpatient/outpatient cases. This role ensures medical necessity aligns with evidence-based guidelines and corporate policies.

The RN must hold an active license, have 4+ years of clinical nursing practice, and be capable of remote work from several western states while maintaining compliance and cost containment goals.