RN Utilization Management

Arkansas Blue Cross and Blue Shield; Little Rock (AR); On-site; USD 65,000 - 90,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an experienced Utilization Management Nurse to perform clinical reviews of prior approvals, network exceptions, benefit inquiries for providers and contracted lines of business. The role evaluates medical necessity using evidence-based criteria, clinical guidelines and policies to support cost effective and quality care.

The ideal candidate holds a Bachelor's degree in Nursing, an active RN license, and at least four years of clinical practice in

Qualifications

• Bachelor's degree in Nursing preferred.
• Active RN license in relevant jurisdiction required.
• Minimum four years of clinical practice in medical-surgical, surgical, ICU or critical care settings.
• Experience in utilization management or medical review preferred.

Responsibilities

• Collaborates with healthcare providers and internal staff to promote quality of care and cost effectiveness.
• Conducts and monitors clinical review cases to ensure medical necessity of services and procedures.
• Performs other duties as assigned and adheres to applicable regulations and policies.
• Maintains current with medical and surgical procedures, products and standards.

Skills

Utilization management

Oral communication

Written communication

Attention to detail

Critical thinking

Collaboration

Documentation interpretation

Time management

Education

Bachelor's degree in Nursing

RN license

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

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

Bachelor's degree in Nursing preferred.

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.

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.

Essential Skils & Abilities

• Experience in utilization management and/or medical review preferred.
• 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.

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.