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.
Certifications
Security Requirements
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
Regular
ADA Requirements
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.
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.
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
Benefits
Health insuranceRemote work options
Additional Information
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.
Arkbluecross · Arkansas Remote