Assistant Medical Director - Utilization Review

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As an Assistant Medical Director at Premera, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including review of clinical documentation using medical policy criteria, guidelines, and member contracts. In addition, you will support clinical programs (disease and case management), as well as the review and adoption of health plan developed review criteria.

This is a work from home opportunity! This role will work 5 days a week, with 1-2 Saturdays per month. We operate on Pacific Standard Time (PST).

What you will do:

Support clinical review activities, including all of the following: pre-service, post-service, concurrent facility-based care, and transitions between levels of care. Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion or network structure. Use clinical expertise to support claims review decisions, including level of care, pricing and complexity assessment, dependent disability status and by report procedure payment determinations.

Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determination and collect additional clinical history in a given case. Consult with nursing and other clinical staff to assess and explore care options for members enrolled in clinical programs such as disease management, case management, and care transition management. Participate in the development, annual review, and approval of company medical review criteria as a member of the Premera Medical Policy Committee.

Leverage clinical knowledge and expertise to support ongoing education for all clinicians involved in medical review. Provide professional advisement to all requests for consultation from within Premera Blue Cross and with contracted practitioners/ facilities. Participate in Inter-Rater Review process to ensure consistency in clinical decision making. Understand and abide by applicable federal, state, and accreditation regulations and standards. Complete all professional continuing education requirements and participate in on-going education/ training as appropriate.

What you will bring:
Physicians license with an MD or DO degree. Unrestricted Washington state licensure or administrative license or ability to obtain within 90 days. Five (5) years of clinical experience. Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association, or other recognized Association acceptable to Premera. (Preferred) Previous experience performing medical necessity and clinical reviews in a health plan setting.

(Preferred) Prior use of clinical criteria sets and clinical pathways, such as MCG ( Milliman Care Guidelines), Interqual®, or others. (Preferred) Familiarity with CPT, ICD, HCPC code…