Care Coordinator - Behavioral Health RN

Premera Blue Cross; United States; Remote; USD 78,000 - 123,000; Full time

Job summary

A leading healthcare company seeks a Care Coordinator - Behavioral Health RN to perform medical necessity reviews and collaborate with various departments to ensure appropriate care. This role requires strong clinical experience and a current RN license. Comprehensive benefits and a commitment to employee growth are offered.

Benefits

Medical Insurance

Dental Insurance

Vision Insurance

401K Match

Tuition Assistance

Paid Time Off

Wellness Incentives

Commuter Benefits

On-site Cafes

Fitness Centers

Qualifications

• Three years of clinical experience required.
• Current State Licensure as a registered nurse required.

Responsibilities

• Perform medical necessity reviews including inpatient and outpatient services.
• Consult with Medical Directors when care does not meet criteria.
• Document clinical information completely and accurately.

Skills

Clinical Experience

Critical Thinking

Collaboration

Education

Bachelor's Degree

Registered Nurse Licensure

Job description

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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.

To better serve our customers, we are fostering a culture that emphasizes employee growth, collaborative innovation, and inspired leadership. We are dedicated to creating an environment where employees can excel and where top talent is attracted, retained, and thrives. As a testament to these efforts, Premera has been recognized on the 2025 America's Dream Employers list. Newsweek honored Premera as one of America's Greatest Workplaces, America's Greatest Workplaces for Inclusion, and America's Greatest Workplaces For Mental Well-Being. Forbes ranked Premera among America’s Best Midsize Employers for the fourth time.

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The Care Coordinator – Behavioral Health RN performs prospective review (benefit advisory/prior authorization), admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of clinical requests from providers. The incumbent partners with Medical Directors and other departments such as National Account Liaisons, Health Care Services, and Claims to ensure appropriate, cost-effective care by applying clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services, procedures, benefit applications, and out-of-network requests. This work covers all lines of business and geographic regions.

What you will do:

• Perform medical necessity reviews including inpatient, concurrent, benefits advisory/prior authorization, retrospective, out-of-network, and treatment setting reviews to ensure compliance with applicable criteria, policies, member eligibility, benefits, and contracts.
• Consult with Medical Directors when care does not meet criteria or policies.
• Document clinical information completely, accurately, and promptly.
• Meet or exceed production and quality metrics.
• Maintain understanding of provider and member contracts, authorization requirements, and clinical criteria including Milliman care guidelines and medical policies.
• Identify Clinical Program opportunities and refer members to appropriate healthcare programs (e.g., case management, engagement, disease management).
• Collaborate with Customer Service, Claims, Sales, and Healthcare Services to ensure consistent processes and application of clinical criteria.
• Ensure compliance with accreditation and regulatory requirements, and that UM decision determinations and timeliness standards are met.
• Support the Plan's Quality Program by participating in quality improvement activities related to internal programs, processes, studies, and projects.

What you will bring:

• Bachelor's degree or four years of work experience (Required)
• Current State Licensure as a registered nurse (Required)
• Three years of clinical experience (Required)
• Psychiatric or substance abuse experience (Strongly Preferred)
• Experience in the health plan industry (Preferred)

Premera total rewards

Our comprehensive benefits include medical, vision, dental, voluntary benefits (including pet insurance), life and disability insurance, retirement plans (including 401K match and pension), wellness incentives, paid time off, tuition assistance, and recognition programs. For hybrid employees, we offer flexibility with on-campus resources, networking, and team engagement. Additional perks include commuter benefits, free parking, on-site cafes, wellness events, fitness centers, and recreational activities.

Equal employment opportunity/affirmative action: Premera is committed to a diverse, inclusive workplace and is an equal opportunity employer. To request accommodations during the application process, contact [e-mail] or call 425-918-4785.

Locations: We hire in multiple states, with some role-specific limitations. The salary range varies by location and experience, with a national range of $78,000 - $122,200 and a plus range of $81,900 - $139,200. We are open to discussing compensation during the interview.

Additional details: Employment type: Full-time; Industry: Insurance; Seniority level: Not Applicable.