RN Utilization Management- Off Shift

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. Arkansas Blue Cross is only seeking applicants for remote positions from the following states: Arkansas, Florida, Georgia, Illinois, Kansas, Louisiana, Minnesota, Mississippi, Oklahoma, South Carolina, Tennessee, Texas, Virginia and Wisconsin.

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.

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-ofnetwork 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.