Utilization Review Nurse
Description
Join Our Team: Do Meaningful Work and Improve People’s Lives
Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.
To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership.
Forbes ranked Premera among America’s 2023 Best Midsize Employers
because we are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!
The Utilization Review Nurse 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.
What you will do:
- Performs medical necessity review that includes: inpatient review, concurrent review, 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 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
- Performs other duties as assigned.
- Bachelor's degree or 4 years’ work experience (Required).
- Current State licensure as a registered nurse where licensing is required by State law (Required).
- 3 years of clinical experience (Required).
- Incumbent located outside Washington State must obtain equivalent WA license within 30 days of accepting the position (Required).
- Utilization Management experience (Preferred)
- Experience working in the health plan industry (Preferred).
- #LI-JG1
- Medical, vision and dental coverage
- Life and disability insurance
- Retirement programs (401K employer match and pension plan)
- Wellness incentives, onsite services, a discount program and more
- Tuition assistance for undergraduate and graduate degrees
- Generous Paid Time Off to reenergize
- Free parking
- National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.