RN Utilization Management

Arkansas Blue Cross and Blue Shield - Little Rock, AR

Job Title: RN Utilization Management

Position: Clinical Review Nurse

Job Type: Full Time

Pay:

Shift:

Work Type: Remote

Location

Address:

City: Little Rock

State: AR

ZIP Code:

Job 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.
Screens, prioritizes and organizes determination requests according to mandates and standards.
Practices nursing within the scope of licensure and adheres to policies, procedures, regulations, URAC standards and individual state regulations.
Makes 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.
Performs other duties as assigned.

Required Skills

Core Skills

Experience in utilization management and/or medical review
Oral & Written Communication
Attention to Detail
Proficiency using basic computer skills in Microsoft Office such as Word, Excel, and Outlook
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

Preferred 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

Requirements

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.

Education: Bachelor's degree in Nursing preferred.

License & Certification:

Registered Nurse (RN) with active, current, unrestricted and recognized in the relevant jurisdiction, state license in good standing

Schedule:

COVID-19 Requirements: Not Specified

Benefits

Not specified

Supplemental Pay

Not specified

Special Notes

Applicants must be eligible to begin work on the date of hire.
Applicants must be currently authorized to work in the United States on a full-time basis.
ARKANSAS BLUE CROSS BLUE SHIELD will NOT sponsor applicants for work visas in this position.
Remote positions are only available from specific states.