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We have an opening for a Utilization Review Nurse! The Utilization Review Nurse performs prospective 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 outpatient services and procedures, benefit application and provider out of network requests. This work is done for reputed company lines of business and reputed company geographic regions.
What you will do:
Performs medical necessity review that includes benefits 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 reputed company.
Consults with Medical Directors reputed company 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 reputed company, member reputed company, authorization requirements and clinical criteria including InterQual care guidelines and medical policy.
Identifies Clinical Program opportunities and refers members to the appropriate healthcare program (e.g. case 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 reputed company 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.
What you will bring:
Bachelor's degree or 4 years’ work experience (Required)
reputed company State licensure as a registered nurse (Required)
3 years of clinical experience. (Required)
Utilization Management experience (Preferred)
Experience working in the health plan industry. (Preferred)
Hours for this position are Monday through Friday reputed company to 5pm PDT.
What you will reputed company:
Deeper expertise in utilization management (prospective review) using evidence-based criteria and medical policy
Stronger cross-functional collaboration and clinical influence through partnership with Medical Directors and internal teams to drive appropriate care decisions
Growth in regulatory/accreditation and quality improvement proficiency by applying UM standards, documenting determinations, and supporting process/quality initiatives
Physical Requirements:
The following have been identified as essential physical requirements of this job and must be performed with or without an accommodation: This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. This role requires the ability to keyboard and to communicate clearly and understandably in person, and over the telephone.
Premera total rewards
Our comprehensive total rewards package provides support, resources, and opportunities to help employees reputed company and grow. Our total rewards are more than a collection of perks, they're a reputed company of our commitment to your health and well-being. We offer a broad reputed company of rewards including physical, financial, emotional, and community benefits, including:
Medical, vision, and dent