Utilization Review Clinician

Workforce Classification:

Telecommuter

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As a Utilization Review Clinician , you will evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols. Your reviews could include benefit advisory and prior authorization, admission, concurrent, and retrospective requests. Using your clinical expertise and critical thinking skills, you will assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests.

You will collaborate with Medical Directors and teams across Premera—including FEP, National Account Liaisons, Health Care Services, and Claims to support appropriate, cost-effective care for members across all lines of business and geographic regions.

_ Most available positions follow a Monday-through-Friday schedule, with a smaller number of positions following a Tuesday-through-Saturday schedule. All schedules are from 8:00 a.m. to 5:00 p.m. Pacific Time. _

_ What you will do: _

• Conduct medical necessity reviews—including inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting reviews to ensure alignment with applicable clinical criteria, medical policies, member eligibility, benefits, and contracts.

• Consult with Medical Directors when requested care does not meet applicable clinical criteria or medical policies.

• Document clinical information completely, accurately, and on time.

• Meet or exceed established productivity and quality standards.

• Maintain a strong working knowledge of provider and member contracts, authorization requirements, Inter Qual Guidelines, medical policies, and other applicable clinical criteria.

• Identify opportunities to connect members with appropriate Clinical Programs, such as case management, the engagement team, and disease management.

• Collaborate with and provide guidance to Customer Service/Claims Operations, Sales and Marketing, and Health Care Services to support consistent workflows and application of clinical criteria.

• Maintain a thorough understanding of accreditation and regulatory requirements, and ensure Utilization Management (UM) decisions and turnaround times remain compliant.

• Support the Plan’s Quality Program by identifying and participating in quality improvement initiatives related to internal programs, processes, studies, and projects.

_ What you will bring: _

• Bachelor’s degree or (4) years’ work experience (Required)

• Current state licensure as a Registered Nurse (Required)

• WA or Compact RN license (Preferred)

• (3) years of clinical experience (Required)

• Utilization Review experience (Preferred)

• Experience working in the health plan industry (Preferred)

_ What you will gain: _

• 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…