Remote Utilization Review Clinician

Premera Blue Cross; United States; Remote; USD 80,000 - 143,000; Full time

Job summary

Premera Blue Cross is hiring a Utilization Review Clinician to evaluate clinical requests for medical necessity and adherence to criteria and protocols. Reviews may include inpatient, concurrent, and prior authorization, with collaboration across Medical Directors and multiple teams.

You will document thoroughly, meet productivity standards, and stay current on clinical policies and accreditation requirements.

Qualifications

• Bachelor’s degree or 4 years of work experience required.
• Active RN licensure in the state.
• WA or Compact RN license preferred.
• 3 years of clinical experience required.
• Utilization Review experience preferred.
• Experience in the health plan industry preferred.

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 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

Clinical reviews

RN licensed

Documentation accuracy

Education

Bachelor’s degree or 4 years work experience

Registered Nurse licensure

WA or Compact RN license

Job description

Premera Blue Cross is hiring a Utilization Review Clinician to evaluate clinical requests for medical necessity and adherence to criteria and protocols. Reviews may include inpatient, concurrent, and prior authorization, with collaboration across Medical Directors and multiple teams.

You will document thoroughly, meet productivity standards, and stay current on clinical policies and accreditation requirements.