Utilization Review Clinician

Job not on LinkedIn

🔥 7 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 - $125.6k / year

⏰ Full Time

🟡 Mid-level

🟠 Senior

🦅 H1B Visa Sponsor

This company has sponsored H1B visas in the past.

👻 Ghost score 0%

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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

• Evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols • Conduct inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting medical necessity reviews • Assess medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests • Consult with Medical Directors when requested care does not meet applicable criteria or policies • Document clinical information completely, accurately, and on time • Meet or exceed productivity and quality standards • Maintain knowledge of provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and clinical criteria • Identify opportunities to connect members with appropriate Clinical Programs • Collaborate with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services • Ensure Utilization Management decisions and turnaround times comply with accreditation and regulatory requirements • Support the Plan’s Quality Program through quality improvement initiatives, programs, processes, studies, and projects

🎯 Requirements

• 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) • Ability to work Monday through Friday or Tuesday through Saturday, 8:00 a.m. to 5:00 p.m. Pacific Time • Ability to keyboard and communicate clearly and understandably in person and over the telephone • Ability to perform sedentary work and occasionally exert up to 10 lbs. of force

🏖️ 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 activities • Fitness and well-being center with in-person and virtual workouts and nutritional counseling