Premera
Healthcare
CareCoordinator-ClinicalAppealsRN
Neural analysis suggests this role is
optimal for Mid+ candidates.
“Care Coordinator - Clinical Appeals RN at Premera. Skills: Clinical appeals, Medical necessity review, Utilization Management. Perform medical necessity review. Consult with Medical Directors”
What You'll Achieve.
Ensure compliance with applicable criteria, medical policy, member eligibility, benefits and contracts; Ensure appropriate cost-effective care; Ensure UM decision determinations and timeliness standards are within compliance
Industry & Context.
What They're Looking For.
Must Have
Bachelor's degree or four (4) years' work experience, Current State Licensure as a registered nurse, Three (3) years of clinical experience
Nice to Have
Utilization Management experience, Experience working in the health plan industry
What You'll Do.
Perform medical necessity review
Consult with Medical Directors
Document clinical information completely
Meet or exceed production and quality metrics
Maintain thorough understanding of Plan's provider contracts
Identify Clinical Program opportunities
Refer members to appropriate healthcare program
educate and consult with Customer Service/Claims Operations
Maintain thorough understanding of accreditation and regulatory requirements
Ensure accreditation and regulatory requirements are accurately followed
Support the Plan's Quality Program
Identify and participate in quality improvement activities
How You'll Work.
Team & Collaboration
Partner with Medical Directors; Partner with Premera Departments; Collaborate with Customer Service/Claims Operations; Collaborate with Sales and Marketing; Collaborate with Health Care Services
Full Job Description
**Workforce Classification:** Telecommuter **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. 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._](https://www.premera.com/visitor/careers#awards) Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog: [_https://healthsource.premera.com/_](https://healthsource.premera.com/). 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. 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, benefit advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews to ensur
Applying for this Care Coordinator - Clinical Appeals RN role?
Most applicants get filtered before a human reads their resume. See if yours makes the cut.
How to Apply on Workday
- Workday has a multi-step form — save your progress after every section.
- "Apply With LinkedIn" can fail or lose data; manual entry is more reliable.
- Watch for the "Submit for Review" final step — hitting "Save" alone does not submit.
- Job requisition numbers are useful when following up with HR by email.
ANONYMOUS · UNFILTERED
What do employees actually say about Premera?
Real rants from real employees. Read before you apply.