Note: The job is a remote job and is open to candidates in USA. Premera Blue Cross is a healthcare organization committed to improving customers’ lives by making healthcare work better. The Utilization Review Clinician evaluates provider clinical requests for medical appropriateness, medical necessity, and alignment with established criteria, while collaborating with Medical Directors and internal teams to support appropriate, cost-effective member care.
Responsibilities
- Conduct medical necessity reviews—including inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting reviews—to ensure alignment with applicable clinical criteria, medical policies, member eligibility, benefits, and contracts
- Consult with Medical Directors when requested care does not meet applicable clinical criteria or medical policies
- Document clinical information completely, accurately, and on time
- Meet or exceed established productivity and quality standards
- Maintain a strong working knowledge of provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and other applicable clinical criteria
- Identify opportunities to connect members with appropriate Clinical Programs, such as case management, the engagement team, and disease management
- Collaborate with and provide guidance to Customer Service/Claims Operations, Sales and Marketing, and Health Care Services to support consistent workflows and application of clinical criteria
- Maintain a thorough understanding of accreditation and regulatory requirements, and ensure Utilization Management (UM) decisions and turnaround times remain compliant
- Support the Plan’s Quality Program by identifying and participating in quality improvement initiatives related to internal programs, processes, studies, and projects
Skills
- Bachelor's degree or (4) years' work experience (Required)
- Current state licensure as a Registered Nurse (Required)
- (3) years of clinical experience (Required)
- The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation: This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body
- This role requires the ability to keyboard and to communicate clearly and understandably in person, and over the telephone
- WA or Compact RN license (Preferred)
- Utilization Review experience (Preferred)
- Experience working in the health plan industry (Preferred)
Benefits
- Medical, vision, and dental coverage with low employee premiums.
- Voluntary benefit offerings, including pet insurance for paw parents.
- Life and disability insurance.
- Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service.
- Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs.
- Generous paid time off to reenergize.
- Tuition assistance for both undergraduate and graduate degrees.
- Employee recognition program to celebrate anniversaries, team accomplishments, and more.
- For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
- Commuter perks.
- Free convenient on-site parking.
- Subsidized on-campus cafes.
- Engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
- Complementary fitness & well-being center offering both in-person and virtual workouts and nutritional counseling.
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