Care Coordinator - Clinical Appeals RN

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The Care Coordinator
- Clinical Appeals performs 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.

• Play a key role in improving healthcare outcomes and ensuring the judicious use of resources.
• Join a team of professionals dedicated to ensuring the highest quality of care while managing utilization effectively.
• Influence critical decisions that impact patient care and organizational efficiency.
• Opportunities for ongoing learning and career development in the ever-changing field of healthcare.
• This position follows a standard schedule of Monday through Friday, 8:00 AM to 5:00 PM Pacific Time

• Performs medical necessity review that includes inpatient review, concurrent review, benefit 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.

• 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
• Experience working in the health plan industry

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