Care Coordinator - Behavioral Health RN

Premera Blue Cross • Tumwater, WA

259d • $78,000 - $122,200 • Remote

About The Position

The Care Coordinator - Behavioral Health RN performs prospective review (benefit advisory/ prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments such as National Account Liaisons, Health Care Services and Claims to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit application and provider out of network requests. This work is done for all lines of business and all geographic regions.

Requirements

• Bachelor's degree or four (4) years' work experience (Required).
• Current State Licensure as a registered nurse where licensing is required by State law (Required).
• Three (3) years of clinical experience (Required).

Nice To Haves

• Psychiatric or substance abuse experience (Strongly Preferred).
• Experience working in the health plan industry (Preferred).

Responsibilities

• Perform medical necessity review that includes inpatient review, concurrent review, benefits advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.
• Consult with Medical Directors when care does not meet applicable criteria or medical policies.
• Document clinical information completely, accurately, and in a timely manner.
• Meet or exceed production and quality metrics.
• Maintain a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman care guidelines and medical policy.
• Identify Clinical Program opportunities and refer members to the appropriate healthcare program (e.g. case management, engagement team, and disease management).
• Collaborate, educate, and consult with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria.
• Maintain a thorough understanding of accreditation and regulatory requirements, and ensure these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance.
• Support the Plan's Quality Program: Identify and participate in quality improvement activities as it relates to internal programs, processes studies, and projects.

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 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.
• 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.

What This Job Offers

• Job Type: Full-time
• Career Level: Mid Level
• Industry: Insurance Carriers and Related Activities
• Education Level: Bachelor's degree