[Hiring] Utilization Review Clinician @Premera Blue Cross

Role Description

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, InterQual 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.

Qualifications

• 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)

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.
• Opportunity to challenge someone to a game of shuffleboard or ping pong while on campus.

Equal Employment Opportunity/Affirmative Action

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at [email protected] or via phone at 425-918-4785.

Salary Information

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience. The salary range for this role is posted below; we generally target up to and around the midpoint of the range.

• National Salary Range: $80,200.00 - $125,600.00
• National Plus Salary Range: $84,200.00 - $143,100.00 (used in higher cost of labor markets including Western Washington and Alaska)

We’re happy to discuss compensation further during the interview because we believe that open communication leads to better outcomes for all. We’re committed to creating an environment where all employees are celebrated for their unique skills and contributions.