Teams at Arkansas Blue Cross and Blue Shield

Perform clinical review of prior authorizations, inpatient/outpatient services and network exceptions to determine medical necessity using evidence-based criteria, corporate policies and URAC standards. Collaborate with providers and internal staff, document determinations, manage queues and calls, promote cost-effective, quality care, and maintain regulatory compliance.

Performs utilization management and clinical reviews for inpatient, outpatient, surgical, diagnostic, and out-of-network services. Evaluates medical necessity using evidence-based criteria, clinical guidelines, policies, mandates, and standards. Collaborates with providers and internal teams to promote quality, appropriate care, cost effectiveness, accessibility, and patient safety. Documents determinations, manages review queues and calls, maintains regulatory compliance, and applies nursing judgment to support healthcare service decisions.

Resolves medical claims that do not automatically adjudicate by reviewing benefits, eligibility, edits, audits, and processing issues. The role researches information using systems, manuals, ICD, CPT, and HCPCS codebooks; communicates with internal staff and medical providers; routes claims; prepares correspondence and forms; and maintains accuracy, productivity, confidentiality, and knowledge of changing procedures.