RN Utilization Management
| Company | Arkansas Blue Cross |
|---|---|
| Location | Arkansas, USA |
| Salary | $Not Provided – $Not Provided |
| Type | Full-Time |
| Degrees | Bachelor’s |
| Experience Level | Mid Level |
Requirements
- Bachelor’s degree in Nursing preferred.
- 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.
- 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.
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; 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.
Preferred Qualifications
- Experience in utilization management and/or medical review preferred.