Utilization Management Nurse

🔥 0 minutes ago

🐊 Florida, Iowa, +5 more states – Remote

🐊 Florida – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🌾 Nebraska – Remote 🌾 North Dakota – Remote 🏰 Missouri – Remote 🤠 Texas – Remote

⏰ Full Time

🟡 Mid-level

🟠 Senior

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Blue Cross and Blue Shield of Nebraska

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1939

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Blue Cross and Blue Shield of Nebraska is a prominent health insurance provider dedicated to serving the state of Nebraska. With over 80 years of experience, the company offers a range of health insurance plans, including group health, individual and family plans, Medicare, dental, and supplemental insurance options. Known for providing peace of mind, they are committed to ensuring member satisfaction and are recognized for their high-quality coverage and exceptional customer service. Blue Cross and Blue Shield of Nebraska also engages with the community through initiatives like the Nebraska Blue Foundation and emphasizes diversity, equity, and inclusion in its practices. The company is an independent licensee of the Blue Cross Blue Shield Association, providing trusted health coverage and resources to its members.

📋 Description

• Conduct prospective, concurrent, retrospective, and post-service clinical claim certification and authorization reviews • Assess medical necessity of inpatient admissions, outpatient services, out-of-network services, and treatment settings • Apply medical policy, evidence-based clinical criteria, standards of care, contract language, benefits, and member eligibility • Educate providers about member benefits, coverage, provider networks, and utilization management processes • Facilitate timely transitions of care and coordinate discharge planning with providers • Identify members appropriate for care management programs and refer them to care management nurses • Collaborate with healthcare providers, internal teams, utilization management specialists, nurses, physicians, medical directors, and pharmacists • Refer cases not meeting clinical criteria or requiring additional review to the Medical Director • Attend weekly rounds concerning high-cost claimants, discharge plans, appropriate care, and member safety • Serve as a resource regarding medical management issues and activities • Maintain compliance with Medicare Advantage, URAC accreditation standards, and other regulatory requirements • Maintain professional licensure and practice within the scope of licensure • Complete special projects such as provider outreach, mentoring, new system implementation, and training

🎯 Requirements

• Associate's degree in nursing • Three (3) years’ clinical practice experience in a health care setting • Active, current, and unrestricted Registered Nurse license from Nebraska or a participating consortium state • Previous experience working in Managed Care organizations • Relevant Medicare or Commercial Insurance experience • Experience in discharge planning, utilization management, case management, or disease management • Ability to work rotating weekend/holiday shifts as needed • Ability to meet department attendance and timeliness requirements • Ability to work effectively in a team environment and maintain positive relationships • Bachelor’s degree in a healthcare field is a preferred additional qualification • Clinical experience in multiple levels of care is a preferred additional qualification • Knowledge of accreditation standards and regulatory requirements is a preferred additional qualification

🏖️ Benefits

• Fully remote work arrangement • Weekend rotation coverage every 6 weeks, working 4 hours • Opportunities for personal and professional growth • Training and development opportunities, including new-hire training, peer mentoring, and system training • Meaningful career and opportunity to make an impact in the community