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Blue Cross Rn Remote Jobs in Pittsburgh, PA (NOW HIRING)

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Blue Cross Rn Remote information

What are the key skills and qualifications needed to thrive as a Blue Cross RN Remote, and why are they important?

To excel as a Blue Cross RN Remote, you need an active RN license, clinical nursing experience (often in case management or utilization review), and strong assessment abilities. Familiarity with electronic medical record (EMR) systems, telehealth platforms, and case management software is typically required, along with certifications like CCM (Certified Case Manager) being advantageous. Exceptional communication, self-motivation, and organizational skills help nurses effectively support members and collaborate virtually with healthcare teams. These competencies ensure quality patient care, regulatory compliance, and efficient service delivery in a remote environment.

What is the difference between Blue Cross Rn Remote vs Blue Cross Lpn Remote?

AspectBlue Cross Rn RemoteBlue Cross Lpn Remote
Required CredentialsRegistered Nurse (RN) licenseLicensed Practical Nurse (LPN) license
Work EnvironmentRemote healthcare support, patient assessmentsRemote patient care, basic clinical tasks
Employer & Industry UsageHealth insurance companies, healthcare providersHealth insurance companies, healthcare providers
Common Search & ComparisonYesYes

Blue Cross Rn Remote and Blue Cross Lpn Remote roles both serve in remote healthcare settings within insurance companies and healthcare providers. The main difference lies in the required credentials: RNs need a registered nurse license, while LPNs require a practical nurse license. RNs typically handle more complex patient assessments, whereas LPNs focus on basic patient care tasks. Both roles are essential in remote healthcare support, but they differ in scope and qualification requirements.

What is a Blue Cross RN Remote?

A Blue Cross RN Remote is a registered nurse who works remotely for Blue Cross Blue Shield, typically supporting members through telehealth, case management, care coordination, and health coaching. These nurses use phone, video calls, and digital platforms to assess patient needs, develop care plans, and provide education and support. Their role helps ensure that members receive high-quality care and guidance without needing in-person visits, making healthcare more accessible and convenient. Blue Cross RNs working remotely may also assist with pre-authorization, utilization management, or disease management programs.

How does a remote Blue Cross RN typically communicate and coordinate care with interdisciplinary team members?

As a remote Blue Cross RN, effective communication with physicians, case managers, social workers, and other healthcare professionals is essential. Most coordination occurs via secure digital platforms, video calls, and phone conferences, allowing for timely updates on patient progress and care plans. Regular virtual meetings and documentation in shared electronic health records ensure seamless teamwork and continuity of care. Building strong digital communication skills and being proactive about follow-ups are key to success in this remote setting.
What are popular job titles related to Blue Cross Rn Remote jobs in Pittsburgh, PA? For Blue Cross Rn Remote jobs in Pittsburgh, PA, the most frequently searched job titles are:
What job categories do people searching Blue Cross Rn Remote jobs in Pittsburgh, PA look for? The top searched job categories for Blue Cross Rn Remote jobs in Pittsburgh, PA are:
What cities near Pittsburgh, PA are hiring for Blue Cross Rn Remote jobs? Cities near Pittsburgh, PA with the most Blue Cross Rn Remote job openings:
Blue Cross Rn Remote jobs near you
Infographic showing various Blue Cross Rn Remote job openings in Pittsburgh, PA as of July 2026, with employment types broken down into 86% Full Time, 7% Part Time, and 7% Contract. Highlights an 7% Hybrid, and 93% Remote job distribution.
Remote/Hybrid Registered Nurse (RN) - Advocacy & Program Integrity (Medical Assistance Expert)

Remote/Hybrid Registered Nurse (RN) - Advocacy & Program Integrity (Medical Assistance Expert)

The CKHobbie Group

Pittsburgh, PA • On-site, Remote

$40 - $42/hr

Full-time

PTO

Posted 8 days ago

Job description


Are you a registered nurse ready to take your career in an exciting newdirection-one where your expertise truly makes a difference? JoinPennsylvania's premier Quality Improvement Organization and step into adynamic role focused on advocacy and program integrity through compliance management. Here, you'll champion the needs of vulnerable populations,safeguard the quality of care, and influence healthcare outcomes on ameaningful scale. Enjoy the freedom of working from home, theflexibility and autonomy to manage your workday, and the opportunity forcontinuous professional growth-all while being part of a passionate,mission-driven team dedicated to improving healthcare across theCommonwealth.
In this rewarding role, you'll use your clinical knowledge outside ofthe traditional bedside setting to review and audit claims, supportprogram integrity initiatives, and advocate for beneficiaries across theCommonwealth. You'll enjoy the flexibility of working from home, theautonomy to manage your work, and meaningful opportunities forprofessional growth-all while contributing to a mission that trulymatters.
What You'll Do
  • Conduct clinical reviews and ensure quality, appropriateness, and compliance with healthcare standards
  • Support program integrity efforts by identifying trends, risks, and opportunities for improvement
  • Advocate for beneficiaries, with a strong focus on protecting and improving care for vulnerable populations
  • Apply nursing judgment to analyze medical records, documentation, and billing data
  • Collaborate with interdisciplinary teams, providers, and stakeholders to promote best practices
  • Contribute to quality improvement initiatives that strengthen healthcare delivery across Pennsylvania

What We're Looking For
  • Active, unrestricted Registered Nurse (RN) license
  • Strong clinical background with the ability to apply nursing judgment analytically
  • Interest in advocacy, quality improvement, and healthcare program integrity
  • Excellent written and verbal communication skills
  • Ability to work independently while managing multiple priorities
  • Comfort with technology and electronic medical records

Experience in utilization review, case management, quality improvement, compliance, or claims review is a plus-but not required.
Why Join Us
  • Mission-driven work with Pennsylvania's leading Quality Improvement Organization
  • Make a real impact on healthcare quality and outcomes for vulnerable populations
  • Remote work - enjoy the convenience and balance of working from home
  • Autonomy and flexibility in how you manage your workday
  • Advocacy-focused role that values your nursing voice and expertise
  • Career development opportunities to grow beyond traditional nursing roles
  • Supportive, collaborative team culture committed to excellence and integrity

If you're a registered nurse seeking purpose-driven work,professional growth, and the flexibility to balance your life andcareer-this is your opportunity. Apply today and help shape the future of healthcare quality in Pennsylvania.
Requirements
Be available as a full-time consultant, approximately 37.5 hours per week;
• Possess a current license to practice as a Registered Nurse issued by the Pennsylvania
State Board of Nursing; or possess a non-renewable temporary practice permit issued
by the Pennsylvania State Board of Nursing. Resources possessing non-renewable
temporary practice permits must obtain licensing as a Registered Nurse within the
one-year period as defined by the Pennsylvania State Board of Nursing;
• Possess a documented work history of three (3) or more years of professional
experience with medical assistance, health care services or human services or any
equivalent combination of experience and training;
• Possess basic computer skills, including familiarity with Microsoft Office programs.
Principal Duties and Responsibilities (RN - Utilization Review / Program Integrity)
  • Conduct clinical utilization reviews by evaluating medical records, treatment plans, and supporting documentation to determine medical necessity, appropriateness, quality, and level of care in accordance with Medical Assistance (MA) program requirements.
  • Apply nursing judgment and evidence-based clinical standards to ensure MA recipients receive safe, appropriate, and high-quality care while supporting program integrity and regulatory compliance.
  • Assess provider billing and documentation to verify compliance with MA policies and identify potential fraud, waste, or abuse.
  • Review clinical documentation submitted through electronic provider portals, telephone communications, fax, and U.S. mail, ensuring completeness and accuracy for utilization determinations.
  • Make authorization determinations by approving, modifying, or denying service requests within RN scope of practice, or refer cases to physician advisors for secondary medical review when medical necessity or level of care is unclear.
  • Collaborate with physician/medical consultants to support peer-to-peer reviews and facilitate discussions with ordering providers regarding clinical justification, appropriate care settings, and service coverage.
  • Accurately document utilization review decisions and clinical rationale in electronic systems, generating authorization notices, denial letters, reason codes, and appeal rights in compliance with regulatory standards.
  • Participate in retrospective, concurrent, and prospective utilization reviews, including re-evaluations of previously denied services upon request by providers or facilities.
  • Review and prepare appeal cases by analyzing medical records, developing exhibits and correspondence, and providing testimony at administrative hearings using knowledge of MA regulations, utilization management principles, and appeal processes.
  • Interpret MA policies, regulations, and utilization management guidelines for internal staff, providers, and stakeholders through consultation, meetings, and educational sessions.
  • Engage in interdisciplinary collaboration with internal departments, medical consultants, legal staff, and external stakeholders to support consistent and defensible utilization determinations.
  • Maintain ongoing professional development through continuing education, conferences, and review of current medical literature to remain current with standards of care, clinical guidelines, and utilization review best practices.
  • Provide cross-coverage in other program areas as needed, maintaining competency through training and updates to ensure continuity of program operations.
  • Respond to inquiries from recipients, providers, legislators, legal offices, and external agencies to explain utilization decisions, coverage policies, and administrative processes.
  • Maintain accurate case records and documentation in accordance with MA regulations, accreditation standards, and organizational policies.
  • Perform related duties and special projects as assigned, with expectations and performance standards communicated for each assignment.
  • When required, work at Department-designated locations. The primary duty location is Pittsburgh, PA, where appropriate workspace, technology, and resources will be provided to support assigned responsibilities.

Benefits
Attractive Compensation plan.Holiday and Vacation program.

Apply