RN Utilization Management: Remote Care & Cost Optimization

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

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