RN Utilization Management

Arkansas Blue Cross Blue Shield • Washington, DC

3d • $66,260 - $84,030 • Remote

About The Position

The Utilization Management Nurse performs clinical reviews of prior approvals, network exceptions, benefit inquiries, inpatient medical/surgical admissions, outpatient procedures, and other contracted lines of business. The role assesses the efficiency and appropriateness of services for medical necessity by interpreting and reviewing evidence-based criteria, clinical guidelines, corporate guidelines and policies, mandates, and standards. The nurse also facilitates and promotes appropriate, high-quality care and cost-effective, cost-containment measures based on evidence.

Requirements

• Active, current, unrestricted Registered Nurse (RN) license in good standing in the relevant jurisdiction and state(s) where job duties are performed.
• At least four years of clinical practice nursing experience in medical-surgical nursing, surgical nursing, intensive care, or critical care.
• Ability to communicate orally and in writing.
• Attention to detail.
• Proficiency with basic computer skills and Microsoft Office applications such as Word, Excel, and Outlook, including navigating 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.

Nice To Haves

• Bachelor's degree in Nursing.
• Experience in utilization management and/or medical review.

Responsibilities

• Collaborate with healthcare providers and internal staff to promote quality of care, cost effectiveness, accessibility, and appropriate service levels.
• Conduct and monitor clinical review cases to assess medical necessity for inpatient and outpatient services, diagnostic procedures, out-of-network services, and surgery; document relevant information and screen, prioritize, and organize determination requests according to mandates and standards.
• Practice nursing within the scope of licensure and adhere to policies, procedures, regulations, URAC standards, and applicable state regulations, making evidence-based decisions that support compliance, appropriate levels of care, and patient safety.
• Promote appropriate, high-quality care and cost-effective, cost-containment measures based on evidence.
• Remain current on medical and surgical procedures, products, healthcare services and drugs, healthcare delivery trends, and enterprise procedures, policies, and contracts.
• Handle incoming and outgoing calls and/or queues from multiple sources proactively and effectively within mandated requirements.
• Perform other duties as assigned.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed