RN Utilization Management

Arkansas Blue Cross Blue Shield; Oregon; Ibrido; USD 80.000 - 105.000; Tempo pieno

Descrizione del lavoro

Arkansas Blue Cross Blue Shield is seeking a licensed RN to perform clinical review of prior approvals, network exceptions, and medical necessity determinations for inpatient and outpatient services. You will interpret criteria and collaborate with providers to promote quality care and cost containment.

The role enables remote work from home across several states, requiring strong communication, critical thinking, and ability to navigate multiple systems while maintaining compliance with URAC

Competenze

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

Mansioni

• Promotes quality of care and cost effectiveness through clinical review.
• Perform clinical review of inpatient/outpatient cases to ensure medical necessity.
• Document determinations and prioritize requests according to standards.
• Adhere to URAC standards and state regulations; ensure patient safety.
• Maintain current knowledge of procedures, policies, contracts.

Conoscenze

Oral & Written Communication

Attention to Detail

Critical Thinking

Team Collaboration

Independent Work

Prioritization

Formazione

Bachelor's degree in Nursing

RN license (active) in good standing

Strumenti

Microsoft Word

Microsoft Excel

Microsoft Outlook

Descrizione del lavoro

To learn more about Arkansas Blue Cross and Blue Shield Hiring Policies, please click here .

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.

LOCATION

Work from home within Arkansas, Washington, Oregon, Utah, Idaho, North Dakota, or Minnesota. Preference will be given to current employees and candidates who reside in Arkansas, Utah, Idaho, and North Dakota.

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

RegularADA Requirements2.1 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.