Care Coordinator – Clinical Appeals RN

🔥 0 minutes ago

🐻 Alaska, Arizona, +25 more states – Remote

🐻 Alaska – Remote 🌵 Arizona – Remote 🏄 California – Remote ⛰️ Colorado – Remote 🐊 Florida – Remote 🥔 Idaho – Remote 🌾 Iowa – Remote 🌪️ Kansas – Remote 🐎 Kentucky – Remote 🦞 Maine – Remote 🦬 Montana – Remote 🎰 Nevada – Remote 🗻 New Hampshire – Remote 🌶️ New Mexico – Remote 🌲 North Carolina – Remote 🌪️ Oklahoma – Remote 🌲 Oregon – Remote 🚗 Michigan – Remote ❄️ Minnesota – Remote 🏰 Missouri – Remote 🌴 South Carolina – Remote 🗿 South Dakota – Remote 🎸 Tennessee – Remote 🤠 Texas – Remote ⛷️ Utah – Remote ☕ Washington – Remote 🧀 Wisconsin – Remote

💵 $80.2k - $143.1k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

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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

• Perform prospective, admission, concurrent, and retrospective medical necessity reviews • Assess medical appropriateness of inpatient admissions, outpatient services, procedures, benefit applications, and out-of-network provider requests • Consult with Medical Directors when care does not meet criteria or medical policies • Document clinical information completely, accurately, and timely • Meet or exceed production and quality metrics • Apply provider contracts, member contracts, authorization requirements, Milliman Care Guidelines, and medical policy • Identify Clinical Program opportunities and refer members to appropriate healthcare programs • Collaborate with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services • Ensure utilization management decisions and timeliness standards comply with accreditation and regulatory requirements • Participate in quality improvement activities, process studies, and projects

🎯 Requirements

• Bachelor's degree or four (4) years’ work experience (REQUIRED) • Current State Licensure as a registered nurse (REQUIRED) • Three (3) years of clinical experience (REQUIRED) • Utilization Management experience • Experience working in the health plan industry • Ability to work Monday through Friday, 8:00 AM to 5:00 PM Pacific Time • Must reside in one of the listed hiring states, subject to role or city limitations

🏖️ Benefits

• Medical, vision, and dental coverage with low employee premiums • Voluntary benefits, including pet insurance • Life and disability insurance • Retirement programs, including a 401K employer match • Pension plan vested after 3 years of service • Wellness incentives and mental well-being resources, including counseling, stress management, 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 activities • Fitness and well-being center with in-person and virtual workouts and nutritional counseling