Assistant Medical Director – Utilization Review

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☕ Washington – Remote

☕ Washington – Remote

💵 $214.5k - $386.1k / year

⏰ Full Time

🔴 Lead

👨‍⚕️ Medical Director

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Premera Blue Cross

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

Founded 1945

🏥 Healthcare

🛡️ Insurance

⚕️ Healthcare Insurance

Healthcare • Insurance • Healthcare Insurance

Premera Blue Cross is an independent health insurance provider, serving businesses and residents of Washington State and Alaska as a licensee of the Blue Cross Blue Shield Association. The company offers a range of health plans including individual, family, employer-based, and Medicare Supplement plans. However, it has announced that it will exit the Medicare Advantage market as of January 1, 2025. Premera is committed to advancing health equity and community support, evident through its Social Impact Program focused on behavioral health and homelessness solutions in Washington and Alaska. Additionally, Premera complies with federal and state civil rights laws, offering language assistance services to ensure equitable care.

📋 Description

• Provide benefit coverage determinations based on medical necessity and contract language • Review clinical documentation using medical policy criteria, guidelines, and member contracts • Support clinical programs including disease management and case management • Support pre-service, post-service, concurrent facility-based care, and transitions between levels of care reviews • Make final coverage decisions based on medical necessity, investigational status, contractual exclusions, or network structure • Use clinical expertise to support claims review decisions involving level of care, pricing, complexity assessment, dependent disability status, and by-report procedure payment determinations • Support peer-to-peer discussions with external physicians and providers regarding denial determinations and collect additional clinical history • Consult with nursing and clinical staff regarding care options for members in clinical programs • Participate in development, annual review, and approval of company medical review criteria through the Premera Medical Policy Committee • Support ongoing education for clinicians involved in medical review • Provide professional consultation to Premera Blue Cross and contracted practitioners/facilities • Participate in the Inter-Rater Review process to ensure consistency in clinical decision-making • Comply with applicable federal, state, and accreditation regulations and standards • Complete continuing education and participate in ongoing education and training

🎯 Requirements

• 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, American Osteopathic Association, or another 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) • Ability to work 5 days a week, including 1–2 Saturdays per month • Ability to operate on Pacific Standard Time (PST)

🏖️ Benefits

• Medical, vision, and dental coverage with low employee premiums • Voluntary benefit offerings, including pet insurance • Life and disability insurance • Retirement programs, including a 401K employer match and pension plan vested after 3 years of service • Wellness incentives, including mental well-being resources, counseling services, stress management programs, and mindfulness programs • Generous paid time off • Tuition assistance for undergraduate and graduate degrees • Employee recognition program • Commuter perks • Free convenient on-site parking • Subsidized on-campus cafes • On-site health and wellness events, coffee connects, disaster preparedness fairs, and other activities • Fitness and well-being center with in-person and virtual workouts and nutritional counseling