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

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 beinga 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’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 a Utilization Review Clinician , you will evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols. Your reviews could include benefit advisory and prior authorization, admission, concurrent, and retrospective requests. Using your clinical expertise and critical thinking skills, you will assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests. You will collaborate with Medical Directors and teams across Premera—including FEP, National Account Liaisons, Health Care Services, and Claims to support appropriate, cost-effective care for members across all lines of business and geographic regions.

_ Most available positions follow a Monday-through-Friday schedule, with a smaller number of positions following a Tuesday-through-Saturday schedule. All schedules are from 8:00 a.m. to 5:00 p.m. Pacific Time. _

_ What you will do: _

• 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.

_ What you will bring: _

• Bachelor’s degree or (4) years’ work experience (Required)

• Current state licensure as a Registered Nurse (Required)

• WA or Compact RN license (Preferred)

• (3) years of clinical experience (Required)

• Utilization Review experience (Preferred)

• Experience working in the health plan industry (Preferred)

_ What you will gain: _

• Play a key role in improving healthcare outcomes and ensuring the judicious use of resources.

• Join a team of professionals dedicated to ensuring the highest quality of care while managing utilization effectively.

• Influence critical decisions that impact patient care and organizational efficiency.

• Opportunities for ongoing learning and career development in the ever-changing field of healthcare.

_ Physical Requirements: _
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.

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.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [e-mail] or via phone at 425-918-4785.

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:

$80,200.00 - $125,600.00

National Plus Salary Range:

$84,200.00 - $143,100.00

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.