Utilization Review Nurse

Premera Blue Cross•Mountlake Terrace, WA

2d•$80,200 - $143,100•Remote

About The Position

The Utilization Review Nurse performs prospective reviews according to established criteria and protocols to determine the medical appropriateness of clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments such as FEP, 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 4 years’ work experience (Required)
Current State licensure as a registered nurse
3 years of clinical experience. (Required)

Nice To Haves

Utilization Management experience (Preferred)
Experience working in the health plan industry. (Preferred)

Responsibilities

Performs 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
Consults with Medical Directors when care does not meet applicable criteria or medical policies
Documents clinical information completely, accurately, and in a timely manner
Meets or exceeds production and quality metrics
Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman care guidelines and medical policy
Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case management, engagement team, and disease management)
Collaborates, educates and consults with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria
Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects
Performs other duties as assigned.

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.