RN Utilization Management: Clinical Review & Cost Control

Arkansas Blue Cross and Blue Shield; Arkansas; Hybrid; USD 70,000 - 90,000; Full time

Benefits offered by this job

Tuition reimbursement

Club Blue onsite gym

Green Leaf Grill onsite restaurants

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to conduct clinical reviews for prior approvals, network exceptions, benefit inquiries, and inpatient/outpatient services. You will evaluate medical necessity using evidence-based criteria and corporate guidelines to promote quality and cost containment.

The role requires a Bachelor's degree in Nursing and an active RN license in good standing, with at least four years of clinical nursing experience in

Qualifications

• Bachelor's degree in Nursing preferred.
• Registered Nurse license in good standing in relevant jurisdiction.

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 information; screens and prioritizes determination requests per mandates and standards.
• Performs other duties as assigned.
• Practices nursing within licensure scope and adheres to policies, procedures, URAC standards and state regulations; making decisions based on facts to ensure compliance, appropriate care, and patient safety.
• Promotes appropriate care and cost containment measures based on evidence.
• Remains current with medical procedures, products, and trends in health care delivery; and enterprise procedures and contracts.
• Works incoming and outbound calls 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

RN license (active, unrestricted)

Tools

Microsoft Outlook

Microsoft Word

Microsoft Excel

Microsoft SharePoint

Job description

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to conduct clinical reviews for prior approvals, network exceptions, benefit inquiries, and inpatient/outpatient services. You will evaluate medical necessity using evidence-based criteria and corporate guidelines to promote quality and cost containment.

The role requires a Bachelor's degree in Nursing and an active RN license in good standing, with at least four years of clinical nursing experience in