Utilization Review Nurse

Workforce Classification:TelecommuterJoin 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.Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: https://healthsource.premera.com/.We have an opening for a Utilization Review Nurse! 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 contractsConsults with Medical Directors when care does not meet applicable criteria or medical policiesDocuments clinical information completely, accurately, and in a timely mannerMeets or exceeds production and quality metricsMaintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman care guidelines and medical policyIdentifies 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 criteriaMaintains 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 complianceSupports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projectsPerforms other duties as assigned.What you will bring:Bachelor's degree or 4 years’ work experience (Required)Current State licensure as a registered nurse or behavioral health clinician where licensing is required by State law (Required)3 years of clinical experience. (Required)CPHM (Certified Professional Health Management) certification, or obtain certification within 36 months of the date of hire. (Required)Utilization Management experience (Preferred)Experience working in the health plan industry. (Preferred)What you will gain: Deeper expertise in utilization management (prospective, concurrent, and retrospective review) using evidence-based criteria and medical policyStronger cross-functional collaboration and clinical influence through partnership with Medical Directors and internal teams to drive appropriate care decisionsGrowth in regulatory/accreditation and quality improvement proficiency by applying UM standards, documenting determinations, and supporting process/quality initiativesPremera total rewardsOur comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including: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, believe it or not, 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 co