Assistant Medical Director - Utilization Review

Premera; Washington; Remote; USD 215,000 - 386,000; Full time

Benefits offered by this job

Medical, vision, and dental coverage

401K employer match

Tuition assistance

Paid time off

Wellness programs

Job summary

Premera seeks an Assistant Medical Director for a work-from-home role, focused on benefit coverage determinations based on medical necessity and contractual language for health plan members. The position supports clinical programs and the development of review criteria, operating PST hours with occasional weekend coverage.

Qualified candidates have an MD/DO, unrestricted WA licensure (or within 90 days), and at least five years of clinical experience with board certification.

Qualifications

• Physician 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.

Responsibilities

• Make final coverage determinations based on medical necessity and contract language.
• Support clinical programs such as disease management and care transitions.
• Engage in peer-to-peer discussions with external physicians.
• Develop and review medical review criteria in collaboration with the Medical Policy Committee.

Skills

Clinical review

Medical policy

Communication with physicians

Education

MD/DO degree

Washington licensure within 90 days

Tools

MCG

InterQual

CPT/ICD coding

Job description

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 to being a 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’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. 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. At Premera, we make healthcare work better. By focusing on improving our customers’ experience purposefully and serving their needs passionately, we make the process easier, less costly, and more positive. Through empathy and advocacy, we change lives.

As the leading health plan in the Pacific Northwest, we provide comprehensive health benefits and services to more than 2 million customers, from individuals to Fortune 100 companies. Our services include innovative programs focused on health management, wellness, prevention, and patient safety. We deliver these programs through health, life, vision, dental, disability, and other related products and services. Premera Blue Cross is headquartered in Mountlake Terrace, WA, with operations in Spokane and Anchorage. The company has operated in Washington since 1933 and in Alaska since 1952. With more than 80 years of experience in the region, we deliver innovation, choice, and expertise.