Care Coordinator - Clinical Appeals RN

Responsibilities

• 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 four (4) years' work experience. (Required)
• Current State Licensure as a registered nurse. (Required)
• Three (3) years of clinical experience. (Required)
• Utilization Management experience. (Preferred)
• Experience working in the health plan industry. (Preferred)
• Hours are Monday through Friday 8am to 5pm PDT.
• What you will gain:
• Strengthen clinical review skills.
• Build utilization management expertise.
• Gain broad health plan experience.
• Partner with cross-functional teams.
• Support quality, cost-effective care.
• Physical Requirements:
• 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.

Benefits

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/ . The Care Coordinator performs clinical appeals, 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 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.

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