RN Utilization Management

Arkansas Blue Cross and Blue Shield; United States; On-site; USD 75,000 - 105,000; Full time

Benefits offered by this job

Tuition reimbursement

Club Blue onsite gym

Green Leaf Grill onsite restaurants

Wellness education incentives

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, inpatient surgical and outpatient procedures to assess medical necessity. You will interpret evidence-based criteria and corporate guidelines to support appropriate care.

The role emphasizes collaboration with providers, documentation of decisions, and adherence to regulatory standards while promoting safe,

Qualifications

• Bachelor's degree in nursing preferred.
• RN with active, unrestricted license in the relevant jurisdiction.
• Minimum four years of clinical nursing in medical-surgical, surgical, ICU or critical care.
• Experience in utilization management or medical review preferred.
• Proficient in Microsoft Office and able to navigate multiple systems.

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 and documents findings.
• Performs duties while adhering to URAC standards, state regulations and safety requirements.
• Promotes cost containment and evidence-based practice through ongoing evaluation.

Skills

Oral & Written Communication

Attention to Detail

MS Office proficiency

Critical Thinking

Collaboration

Documentation interpretation

Independent work

Education

Bachelor's degree in Nursing

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

Education

EDUCATION Bachelor's degree in Nursing preferred.

Licensing/Certification

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

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.

Hiring Range 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.

Employment Type Regular ADA Requirements

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.

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.