Premera
Healthcare
UtilizationReviewNurse
“Utilization Review Nurse at Premera. Skills: Utilization review, Clinical review, Medical appropriateness assessment. Perform medical necessity review. Perform benefits advisory review”
What You'll Achieve.
Ensure compliance with applicable criteria; Ensure compliance with medical policy; Ensure compliance with member eligibility; Ensure compliance with benefits; Ensure compliance with contracts; Ensure UM decision determinations are within compliance; Ensure UM timeliness standards are within compliance
Industry & Context.
What They're Looking For.
Must Have
Bachelor's degree or 4 years work experience, Current State licensure as a registered nurse, 3 years of clinical experience
Nice to Have
Utilization Management experience, Experience in health plan industry
What You'll Do.
Perform medical necessity review
Perform benefits advisory review
Perform prior authorization review
Perform retrospective review
Perform out of network review
Perform appropriateness of treatment setting reviews
Ensure compliance with criteria
Ensure compliance with medical policy
Ensure compliance with member eligibility
Ensure compliance with benefits
Ensure compliance with contracts
Consult with Medical Directors
Document clinical information completely
Document clinical information accurately
Document clinical information timely
Meet production metrics
Maintain understanding of provider contracts
Maintain understanding of member contracts
Maintain understanding of authorization requirements
Maintain understanding of clinical criteria
Identify Clinical Program opportunities
Refer members to healthcare program
Collaborate with Customer Service
Collaborate with Claims Operations
Collaborate with Sales
Collaborate with Marketing
Collaborate with Health Care Services
Ensure consistent work processes
Ensure procedural application of clinical criteria
Maintain understanding of accreditation requirements
Maintain understanding of regulatory requirements
Ensure accreditation requirements are followed
Ensure regulatory requirements are followed
Ensure UM decision timeliness standards compliance
Support Quality Program
Participate in quality improvement activities
Perform other duties as assigned
How You'll Work.
Team & Collaboration
Partner with Medical Directors; Partner with Premera Departments; Collaborate with internal teams
Applying for this Utilization Review Nurse role?
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