RN Utilization Management - Off Shift

Arkansas Blue Cross Blue Shield•Arkansas Remote, AR

5d•Hybrid

About The Position

The RN Utilization Management Nurse performs clinical review of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions and outpatient procedures for providers, and all 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. This role is responsible for providing utilization management services over the weekend, outside of normal business week hours.

Requirements

Bachelor's degree in Nursing preferred.
Registered Nurse (RN) with current active state license in good standing in the state(s) where job duties are performed required.
Minimum four (4) years' clinical practice nursing experience consisting of some experience in each of the following areas: medical-surgical nursing, surgical nursing, intensive care or critical care nursing.
Experience in utilization management and/or medical review required.
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.

Nice To Haves

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

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.
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.
Provides primary utilization management review and communication for both scheduled workdays during the regular workweek AND scheduled weekend period.
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.