RN Utilization Management

Arkansas Blue Cross and Blue Shield; Arkansas; Hybrid; USD 70,000 - 100,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to perform clinical review of prior approvals, network exceptions, benefit inquiries, inpatient admissions and outpatient procedures. The role evaluates medical necessity using evidence-based criteria and promotes cost containment through informed decision making.

The candidate should hold a Bachelor's degree in Nursing and an active RN license, with at least four years of clinical nursing experience in relevant

Qualifications

• Bachelor's degree in Nursing; RN licensure in relevant jurisdiction.
• Four+ years of clinical nursing experience in medical-surgical, surgical, ICU/critical care or related areas; utilization management experience preferred.

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care and cost effectiveness.
• Conducts and monitors clinical reviews to ensure medical necessity for inpatient and outpatient services; documents findings.
• Performs duties within licensure scope and adheres to policies, procedures, URAC standards and state regulations.
• Promotes appropriate care and cost containment based on evidence; stays current with medical procedures and contracts.
• Handles incoming/outbound calls and queues from multiple sources within mandated requirements.

Skills

Active Listening

Analytical Decision Making

Critical Thinking

Data Analysis

Educational Development

Interpersonal Relationship Management

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Oral Communications

Problem Sensitivity

Sound Judgment

Team Development

Time Management

Written Communication

Education

Bachelor's degree in Nursing

Registered Nurse License

Tools

Microsoft Outlook

Microsoft SharePoint

Microsoft Word

Excel

Job description

Job Summary

Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and/or other contracted lines of business. This role assesses and evaluates the efficiency and appropriateness of services for medical necessity through interpretation and review with evidenced-based criteria, clinical guidelines, corporate guidelines and policies and mandates and standards. Incumbent also facilitates and promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.

Requirements

EDUCATION Bachelor's degree in Nursing preferred.

LICENSING/CERTIFICATION Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing in the state(s) where job duties are performed required.

EXPERIENCE Minimum four (4) years' clinical practice nursing experience in at least one of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing. Experience in utilization management and/or medical review preferred.

ESSENTIAL SKILS & ABILITIES

Oral & Written Communication Attention to Detail Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook, including the ability to navigate multiple systems and keyboarding. Ability to prioritize and make sound nursing judgments through critical thinking. Ability to build collaborative relationships. Ability to interpret complex documentation. Ability to work independently.

Skills

• Active Listening
• Analytical Decision Making
• Critical Thinking
• Data Analysis
• Educational Development
• Interpersonal Relationship Management
• Microsoft Outlook
• Microsoft SharePoint
• Microsoft Word
• Oral Communications
• Problem Sensitivity
• Sound Judgment
• Team Development
• Time Management
• Written Communication

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility and appropriateness of service levels.
• Conducts and monitors clinical review cases to ensure medical necessity of inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; documenting all relevant and specific information; and screens, prioritizes and organizes determination requests according to mandates and standards.
• Performs other duties as assigned.
• Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations; making decisions based on facts and evidence to ensure compliance, appropriate level of care, and patient safety.
• Promotes appropriate care and quality toward cost effective and cost containment measures based on evidence.
• Remains current with up-to-date medical and surgical procedures, products, healthcare services and drugs, general trends in health care delivery; and enterprise procedures, policies and contracts.
• Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively.

Certifications Security Requirements

This position is identified as level three (3). This position must ensure the security and confidentiality of records and information to prevent substantial harm, embarrassment, inconvenience, or unfairness to any individual on whom information is maintained. The integrity of information must be maintained as outlined in the company Administrative Manual.

Segregation of Duties

Segregation of duties will be used to ensure that errors or irregularities are prevented or detected on a timely basis by employees in the normal course of business. This position must adhere to the segregation of duties guidelines in the Administrative Manual.

Employment Type

Regular ADA Requirements 2.1 General Office Worker, Semi-Active, Campus Travel - Someone who normally works in an office setting or remotely, periodically has lifting and carrying requirements up to 40 lbs and routinely travels for work within walking distance of location of primary work assignment as essential functions of the job.

Arkansas Blue Cross is consistently ranked as one of the best places to work in Central Arkansas. Why? We Love our Employees At Arkansas Blue Cross, we care about the health, wellness, and education of our employees.

We offer many great incentives such as: Tuition reimbursement.

Club Blue, a free, onsite gym to encourage exercise.

Green Leaf Grill and Green Leaf Grill Express, onsite restaurants in Little Rock that promote healthy eating.

Incentives for wellness education and exercise

We Love our Culture The average tenure is 10 years with hundreds of employees having been here 15 years or longer. Our inclusive culture brings employees together to connect while celebrating our differences.

We Love our Community Our employees often volunteer within their communities, at charity events, walks and runs, schools and nonprofits. When disasters strike, our employees help wherever they are needed. It’s just another way we show that Blue cares.