Remote Utilization RN — Care & Cost Optimizer

Arkansas Blue Cross Blue Shield; Little Rock (AR); Remote; USD 68,000 - 95,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield seeks an Utilization Management Nurse to conduct clinical reviews for prior approvals and related services. The role requires an active RN license, a Bachelor’s in Nursing preferred, and at least four years of clinical nursing experience in medical-surgical, surgical, ICU, or critical care settings.

The nurse will assess medical necessity, use evidence-based criteria, and promote cost-effective, high-quality care while complying with corporate policies.

Qualifications

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

Responsibilities

• Perform clinical review of prior approvals, network exceptions, benefit inquiries, and admissions for providers and other lines of business.
• Assess and determine medical necessity through evidence-based criteria and guidelines.
• Facilitate cost-effective and quality care while adhering to policies and standards.
• Promote and maintain up-to-date knowledge of medical procedures, products, and healthcare trends.
• Work from home within Arkansas and specified states.

Skills

Clinical review

Utilization management

Critical thinking

Communication

Education

Bachelor's in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

Job description

Arkansas Blue Cross and Blue Shield seeks an Utilization Management Nurse to conduct clinical reviews for prior approvals and related services. The role requires an active RN license, a Bachelor’s in Nursing preferred, and at least four years of clinical nursing experience in medical-surgical, surgical, ICU, or critical care settings.

The nurse will assess medical necessity, use evidence-based criteria, and promote cost-effective, high-quality care while complying with corporate policies.