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.
Requirements
Bachelor's degree or 4 years' work experience (Required)
Current State licensure as a registered nurse
3 years of clinical experience. (Required)
Utilization Management experience (Preferred)
Experience working in the health plan industry. (Preferred)
What you will gain:
Deeper expertise in utilization management (prospective, concurrent, and retrospective review) using evidence-based criteria and medical policy
Stronger cross-functional collaboration and clinical influence through partnership with Medical Directors and internal teams to drive appropriate care decisions
Growth in regulatory/accreditation and quality improvement proficiency by applying UM standards, documenting determinations, and supporting process/quality initiatives
Premera total rewards
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.
Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
Employee recognition prog
Benefits
Health insuranceDental insuranceVision insurance401(k)
Additional Information
Workforce Classification:
Telecommuter
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/ .
We have an opening for a Utilization Review Nurse ! The Utilization Review Nurse performs prospective 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 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.
Premera · WA Other Telecommuter