RN Utilization Management: Remote Care & Cost Optimization

Arkansas Blue Cross and Blue Shield; Little Rock (AR); On-site; USD 70,000 - 100,000; Full time

Job summary

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to conduct clinical reviews of prior approvals, network exceptions, and inpatient/outpatient services. The role focuses on medical necessity interpretation, guideline application, and cost containment to promote quality care.

A RN license and 4+ years of relevant nursing experience are required, with a preferred Bachelor's in Nursing.

Qualifications

• RN with active license in the relevant jurisdiction.
• Bachelor's degree in Nursing preferred.
• Minimum four years of clinical practice nursing experience in medical-surgical, surgical, ICU or critical care.

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 inpatient/outpatient services and procedures.
• Documents all relevant information and screens requests according to mandates and standards.
• Practices nursing within licensure scope and complies with policies and regulations.

Skills

Active Listening

Analytical Decision Making

Critical Thinking

Data Analysis

Oral Communications

Written Communication

Time Management

Attention to Detail

Problem Sensitivity

Sound Judgment

Team Development

Interpersonal Relationship Management

Education

Bachelor's Degree in Nursing

Tools

Microsoft Word

Microsoft Excel

Microsoft Outlook

Microsoft SharePoint

Microsoft Office Suite

Job description

Arkansas Blue Cross and Blue Shield is seeking an Utilization Management Nurse to conduct clinical reviews of prior approvals, network exceptions, and inpatient/outpatient services. The role focuses on medical necessity interpretation, guideline application, and cost containment to promote quality care.

A RN license and 4+ years of relevant nursing experience are required, with a preferred Bachelor's in Nursing.