Assistant Medical Director - Utilization Review

Premera Blue Cross•WA Western Telecommuter, WA

1d•$214,500 - $386,100•Remote

About The Position

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 being a 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’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace. Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/. As an Assistant Medical Director at Premera, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including review of clinical documentation using medical policy criteria, guidelines, and member contracts. In addition, you will support clinical programs (disease and case management), as well as the review and adoption of health plan developed review criteria. This is a work from home opportunity! This role will work 5 days a week, with 1-2 Saturdays per month. We operate on Pacific Standard Time (PST).

Requirements

Physicians 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.

Nice To Haves

Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association, or other recognized Association acceptable to Premera.
Previous experience performing medical necessity and clinical reviews in a health plan setting.
Prior use of clinical criteria sets and clinical pathways, such as MCG ( Milliman Care Guidelines), Interqual®, or others.
Familiarity with CPT, ICD, HCPC code sets, and RBRVS pricing concepts.

Responsibilities

Support clinical review activities, including all of the following: pre-service, post-service, concurrent facility-based care, and transitions between levels of care. Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion or network structure.
Use clinical expertise to support claims review decisions, including level of care, pricing and complexity assessment, dependent disability status and by report procedure payment determinations.
Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determination and collect additional clinical history in a given case.
Consult with nursing and other clinical staff to assess and explore care options for members enrolled in clinical programs such as disease management, case management, and care transition management.
Participate in the development, annual review, and approval of company medical review criteria as a member of the Premera Medical Policy Committee.
Leverage clinical knowledge and expertise to support ongoing education for all clinicians involved in medical review.
Provide professional advisement to all requests for consultation from within Premera Blue Cross and with contracted practitioners/ facilities.
Participate in Inter-Rater Review process to ensure consistency in clinical decision making.
Understand and abide by applicable federal, state, and accreditation regulations and standards. Complete all professional continuing education requirements and participate in on-going education/ training as appropriate

Benefits

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.
Tuition assistance for both undergraduate and graduate degrees.
Employee recognition program to celebrate anniversaries, team accomplishments, and more.
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.
Challenge someone to a game of shuffleboard or ping pong while on campus.