Arkansas Blue Cross and Blue Shield · 15 hours ago
RN Pharmacy Utilization Management
United States
Full-time
Remote
Mid Level
4+ years expArkansas Blue Cross and Blue Shield is seeking a Pharmacy Utilization Management nurse to perform clinical reviews of pharmaceutical therapies. The role involves assessing medical necessity and promoting cost-effective care based on evidence and guidelines.
Financial ServicesHealth CareNon Profit
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 from a pharmaceutical standpoint 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 pharmaceuticalcare and quality toward cost effective and cost containment measures based on evidence
Remains current with up-to-date pharmaceutical and healthcare services, in addition to general trends in health care delivery; as well as enterprise procedures, policies and contracts
Works incoming and outbound calls and/or queues from multiple sources within mandated requirements proactively and effectively
Qualification
Required
Bachelor's degree in Nursing
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
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
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
Preferred
Bachelor's degree in Nursing preferred
Experience in utilization management and/or medical review preferred
Previous pharmacy technician experience desirable
Company
Arkansas Blue Cross and Blue Shield
Arkansas Blue Cross and Blue Shield provides reliable insurance plans to Arkansans while being a valuable community partner.
1001-5000 employees
Funding
Current Stage
Late StageLeadership Team
Curtis Barnett
President and CEO
Recent News
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