Utilization Review Clinician
About The Position
As a Utilization Review Clinician, you will evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols. Your reviews could include benefit advisory and prior authorization, admission, concurrent, and retrospective requests. Using your clinical expertise and critical thinking skills, you will assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests. You will collaborate with Medical Directors and teams across Premera—including FEP, National Account Liaisons, Health Care Services, and Claims—to support appropriate, cost-effective care for members across all lines of business and geographic regions.
Requirements
- Bachelor's degree or (4) years’ work experience (Required)
- Current state licensure as a Registered Nurse (Required)
- (3) years of clinical experience (Required)
Nice To Haves
- WA or Compact RN license (Preferred)
- Utilization Review experience (Preferred)
- Experience working in the health plan industry (Preferred)
Responsibilities
- Conduct medical necessity reviews—including inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting reviews—to ensure alignment with applicable clinical criteria, medical policies, member eligibility, benefits, and contracts.
- Consult with Medical Directors when requested care does not meet applicable clinical criteria or medical policies.
- Document clinical information completely, accurately, and on time.
- Meet or exceed established productivity and quality standards.
- Maintain a strong working knowledge of provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and other applicable clinical criteria.
- Identify opportunities to connect members with appropriate Clinical Programs, such as case management, the engagement team, and disease management.
- Collaborate with and provide guidance to Customer Service/Claims Operations, Sales and Marketing, and Health Care Services to support consistent workflows and application of clinical criteria.
- Maintain a thorough understanding of accreditation and regulatory requirements, and ensure Utilization Management (UM) decisions and turnaround times remain compliant.
- Support the Plan’s Quality Program by identifying and participating in quality improvement initiatives related 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, 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.
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What This Job Offers
Job Type
Full-time
Career Level
Mid Level
