Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determinations and collecting additional clinical history pertinent to case determinations.
Consult with nursing and other clinical staff to assess and explore care options for members enrolled.
Participate in the development, annual review, and approval of company medical review criteria as a Premera Medical Policy Committee member.
Participate in Inter-Rater Reliability evaluations to ensure consistency in clinical decision-making.
Respond in a professional manner to all requests for consultation from within Premera Blue Cross and from contracted practitioners and facilities.
Support member and provider appeals by participating in the appeals process and conducting secondary reviews as needed.
Fulfill all professional continuing education requirements and participate in ongoing education/training as appropriate.
This role will be part-time, 20 hours a week.
Requirements
Licensed Physician with an MD or DO degree (Required)
Unrestricted Washington MD or Alaska DO state licensure, or ability to obtain within 90 days.
Current board certification in psychiatry from the American Board of Psychiatry and Neurology.
Five (5) years of clinical experience in psychiatry (Required)
Previous experience performing medical necessity and clinical reviews in a health plan setting. (Preferred)
Familiarity or experience with clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines) or InterQual. (Preferred)
Familiarity or experience with CPT, ICD, and HCPCS code sets and resource-based relative value scale (RBRVS) pricing concepts. (Preferred)
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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 program to celebrate anniversaries, team accomplishments, and more.
For our hybrid employees, our on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
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 aff
Benefits
Health insuranceDental insuranceVision insurance401(k)
Additional Information
Workforce Classification:
Telecommuter
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As the Assistant Medical Director, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including a review of clinical documentation using medical policy criteria, guidelines, and member contracts at Premera Blue Cross. The Assistant Medical Director supports clinical programs (disease and case management), and the review and adoption of health plan developed review criteria.
Premera · Mountlake Terrace, WA