[Hiring] Care Coordinator - Clinical Appeals RN @Premera Blue Cross

Role Description

The Care Coordinator performs clinical appeals, 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. This work is done for all lines of business and all geographic regions.

• 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.
• Performs other duties as assigned.

Qualifications

• 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. (Preferred)
• Experience working in the health plan industry. (Preferred)

Requirements

• Hours are Monday through Friday 8am to 5pm PDT.

Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance for paw parents.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service.
• Wellness incentives with a wide range of mental well-being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs.
• Generous paid time off to reenergize.
• Tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program to celebrate anniversaries, team accomplishments, and more.
• For hybrid employees, on-campus model provides flexibility to create your own routine with access to on-site resources, networking opportunities, and team engagement.
• Commuter perks make your trip to work less impactful on the environment and your wallet.
• Free convenient on-site parking.
• Subsidized on-campus cafes make lunchtime connections with colleagues fun and affordable.
• Participate in engaging on-site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more.
• Complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
• Challenge someone to a game of shuffleboard or ping pong while on campus.