Utilization Review Nurse (RN) PRIMARY PURPOSE: To provide timely, evidence-based utilization review services to maximize quality care and cost-effective outcomes. ARE YOU AN IDEAL CANDIDATE? We are looking for enthusiastic candidates who thrive in a collaborative environment, who are driven to deliver great work. ESSENTIAL FUNCTIONS and RESPONSIBILITIES - Identifies treatment plan request(s) and obtains and analyzes medical records that support the request. - Clarifies unclear treatment plan requests by contacting the requesting provider's office. - Utilizes evidence-based criteria and jurisdictional guidelines to form utilization review determinations. - Pursues Physician Advisor services when treatment plan requests do not meet evidenced-based criteria. - Negotiates treatment plan requests with requesting provider when medically appropriate and jurisdictionally allowed. - Channels certified treatment plan requests to preferred vendors as necessary - Documents all utilization review outcomes in utilization review software. - Communicates and works with claim examiners as needed to provide clinical information to resolve issues. - Maintains a score of 90% or higher on monthly internal utilization review audits. - Meets productivity goals as outlined by supervisor. ADDITIONAL FUNCTIONS and RESPONSIBILITIES - Performs other duties as assigned. QUALIFICATIONS Education & LicensingActive unrestricted RN license in a state or territory of the United States required. Associate degree from an accredited college or university required. Bachelor’s degree from an accredited college or university preferred. Utilization review based certification preferred. ExperienceFour (4) years of related experience or equivalent combination of education and experience required to include two (2) years of recent clinical practice or one (1) year of recent utilization review. Skills & Knowledge - Strong clinical practice knowledge - Knowledge of the insurance industry and claims processing - Excellent oral and written communication, including presentation skills - PC literate, including Microsoft Office products - Analytical and interpretive skills - Strong organizational skills - Excellent interpersonal skills - Excellent negotiation skills - Ability to work in a team environment - Ability to meet or exceed Performance Competencies

Job Summary: Under the supervision of a registered nurse the Utilization Review Nurse will provide professional assessment and review for the medical necessity of treatment requests and plans. The standard work schedule is Monday through Friday, 8:00 AM–5:00 PM Pacific Time, with rotating weekend coverage as required. What You'll Actually Do Essential Functions/Responsibilities/Duties: · Provide first level review for all outpatient and ancillary pre-certification requests for medical appropriateness; all inpatient hospital stays including mental health, substance abuse, skilled nursing and rehabilitation for medical necessity; and all post claim or post service reviews. · Ensure proper referral to medical director for denial authorizations through independent review organizations (IRO). · Work with hospital staff to prepare patients for discharge and ensure a smooth transition to the next level of care. · Refer requests that fall outside of established guidelines to advance review or senior care consultants. · Process appeals for non-certification of services; complete non-certification letters when appropriate. · Review plan document for benefit determinations; attempt to redirect providers and patients to PPO providers. · Identify and refer potential cases to case management, wellness, chronic disease and Nurturing Together program. · Complete documentation for all reviews in Eldorado/Episodes; maintain confidentiality. · Utilize MCG guidelines, medical policies, Medscape, and NCCN. · Ability to meet productivity, quality, and turnaround times daily. · Assists with department operations and implementations Qualifications What You Bring to Our Team Education and Experience: · Current LVN license in the United States or U.S. territory. · 1+ years of clinical experience required. Required Knowledge, Skills, and Abilities: · Knowledge of medical claims and ICD-10, CPT, HCPCS coding. · Proficiency in software applications including, but not limited to, Microsoft Word, Microsoft Excel, Microsoft PowerPoint and Outlook

At AZ Blue, we have a hybrid workforce strategy, called Workability, that offers flexibility with how and where employees work. Our positions are classified as hybrid, onsite or remote. While the majority of our employees are hybrid, the following classifications drive our current minimum onsite requirements: - Hybrid People Leaders: must reside in AZ, required to be onsite at least twice per week - Hybrid Individual Contributors: must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per week - Hybrid 2 (Operational Roles such as but not limited to: Customer Service, Claims Processors, and Correspondence positions): must reside in AZ, unless otherwise cited within this posting, required to be onsite at least once per month - Onsite: daily onsite requirement based on the essential functions of the job - Remote: not held to onsite requirements, however, leadership can request presence onsite for business reasons including but not limited to staff meetings, one-on-ones, training, and team building Please note that onsite requirements may change in the future, based on business need, and job responsibilities. Most employees should expect onsite requirements and at a minimum of once per week. This remote work opportunity requires residency, and work to be performed, within the State of Arizona. PURPOSE OF THE JOB - Responsible for identifying, researching, processing, resolving, and responding to inquiries from internal and external customers with emphasis on excellence, privacy, compliance and versatility within the health insurance industry. QUALIFICATIONS REQUIRED QUALIFICATIONS Required Work Experience - 2 years of experience in clinical field of practice, health insurance, or other health care related field Required Education - Associate’s Degree in general field of study or Post High School Nursing Diploma or Certification (LPN only) from an approved program Required Licenses - Active, current, and unrestricted license to practice in the State of Arizona (or an endorsement to work in Arizona) as a behavioral health professional such as LCSW, LPC, LISAC LMFT, or licensed psychologist (Psy.D. or Ph.D.), OR an active, current, and unrestricted license to practice nursing in either the State of Arizona or another state in the United States recognized by the Nursing Licensure Compact (NLC) as an RN, OR an active, current, and unrestricted license to practice in the State of Arizona as an LPN.

Primary Responsibilities: - Perform thorough telephonic nursing assessment and clinical review to determine appropriate triage protocol to utilize for nurse care advice. Ensure members are directed to the most appropriate level of care at contracted facilities - Assess, plan and implement care strategies that are individualized by patient and directed toward the most appropriate, least restrictive level of care - Utilize both company and community based resources to establish a safe and effective case management plan for hospitalized members - Collaborate with member, family and health care providers to develop an individualized plan of care that encompasses both acute care episode and post hospital discharge plan - Communicate with all stakeholders the required health related information to ensure quality coordinated care and services are provided expeditiously to all members - Advocate for members and families as needed to ensure the member's needs and choices are fully represented and supported by the health care team - Utilize approved clinical criteria (MCG)  to assess and determine appropriate level of care for  members - Understand insurance products, benefits, coverage limitations, insurance and governmental regulations as it applies to the health plan - This department is open 24/7. Candidates must be available to work a flexible schedule 11:00 am - 9:30 pm 4 days per week. This department works a rotation of weekends and holidays You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Required Qualifications: - Registered Nurse with active unrestricted license in the State of Nevada  - 2+ years of varied clinical experience in a hospital setting  - Basic to intermediate level of proficiency using a PC in a Windows environment, including Microsoft Word  - Willing and able to work rotating weekends and holidays