Assistant Medical Director - Utilization Review

Premera Blue Cross; United States; Remote; USD 215.000 - 386.000; Vollzeit

Benefits dieser Stelle

Commuter perks

Free on-site parking

On-site cafes

Fitness & well-being center

Campus activities

Tuition assistance

Pension plan

401K employer match

Generous paid time off

Zusammenfassung

Premera Blue Cross is seeking an Assistant Medical Director to perform benefit coverage determinations based on medical necessity and contract language. You will support clinical programs, review criteria, and collaborate with external providers while working remotely on PST hours.

We require an MD/DO with unrestricted WA licensure or ability to obtain in 90 days, and 5 years of clinical experience. Board certification is preferred, and familiarity with guidelines like MCG and InterQual is a

Qualifikationen

• Active medical license and board certification in good standing.
• Minimum five years of clinical experience.
• Experience performing medical necessity reviews in health plan settings preferred.
• Familiarity with medical review criteria and pathways.

Aufgaben

• Support clinical review activities including pre-service and post-service determinations.
• Act as final decision maker for coverage decisions based on medical necessity.
• Discuss denial determinations with external physicians and obtain additional clinical history.
• Collaborate with nursing and clinical staff on care options for clinical programs.
• Participate in development and annual review of medical review criteria.
• Educate clinicians involved in medical review; provide advisement for consult requests.
• Participate in inter-rater reviews to ensure consistency.
• Maintain compliance with applicable federal/state regulations and ongoing CE.

Kenntnisse

Clinical decision making

Communication with providers

Independent work

Policy interpretation

Ausbildung

MD or DO degree

WA medical license (unrestricted) or ability to obtain in 90 days

ABMS/AOA board certification

Tools

MCG / Milliman Care Guidelines

InterQual

CPT/ICD knowledge

Jobbeschreibung

Workforce Classification:

Telecommuter

Join Our Team: Do Meaningful Work and Improve People’s Lives

Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

Premera is committed tobeinga workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development,we’reable to better serve our customers.It’sthis commitment that has earned us recognition as one of the best companies to work for.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/.

As an Assistant Medical Director at Premera, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including review of clinical documentation using medical policy criteria, guidelines, and member contracts. In addition, you will support clinical programs (disease and case management), as well as the review and adoption of health plan developed review criteria.

This is a work from home opportunity! This role will work 5 days a week, with 1-2 Saturdays per month. We operate on Pacific Standard Time (PST).

What you will do:

• Support clinical review activities, including all of the following: pre-service, post-service, concurrent facility-based care, and transitions between levels of care. Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion or network structure.
• Use clinical expertise to support claims review decisions, including level of care, pricing and complexity assessment, dependent disability status and by report procedure payment determinations.
• Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determination and collect additional clinical history in a given case.
• Consult with nursing and other clinical staff to assess and explore care options for members enrolled in clinical programs such as disease management, case management, and care transition management.
• Participate in the development, annual review, and approval of company medical review criteria as a member of the Premera Medical Policy Committee.
• Leverage clinical knowledge and expertise to support ongoing education for all clinicians involved in medical review.
• Provide professional advisement to all requests for consultation from within Premera Blue Cross and with contracted practitioners/ facilities.
• Participate in Inter-Rater Review process to ensure consistency in clinical decision making.
• Understand and abide by applicable federal, state, and accreditation regulations and standards. Complete all professional continuing education requirements and participate in on-going education/ training as appropriate

What you will bring:

• Physicians license with an MD or DO degree.
• Unrestricted Washington state licensure or administrative license or ability to obtain within 90 days.
• Five (5) years of clinical experience.
• Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association, or other recognized Association acceptable to Premera. (Preferred)
• Previous experience performing medical necessity and clinical reviews in a health plan setting.(Preferred)
• Prior use of clinical criteria sets and clinical pathways, such as MCG ( Milliman Care Guidelines), Interqual, or others. (Preferred)
• Familiarity with CPT, ICD, HCPC code sets, and RBRVS pricing concepts. (Preferred)

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they’re a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• 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, believe it or not, 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, just to name a few.
• Generous paid time off to reenergize.
• Looking for continuing education? We have 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 make your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

Premera is hiring in the following states, with some limitations based on role or city:

Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin_._

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

National Salary Range:

$214,500.00 - $386,100.00

National Plus Salary Range:

$214,500.00 - $386,100.00

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska_._

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.