Care Coordinator – Clinical Appeals RN
Posted 12ds ago
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Job Description
Care Coordinator reviewing clinical appeals and medical necessity for Premera’s healthcare insurance plans. Applying nursing expertise to utilization management, provider requests, and patient care decisions.
Responsibilities:
- Perform prospective, admission, concurrent, and retrospective medical necessity reviews
- Assess medical appropriateness of inpatient admissions, outpatient services, procedures, benefit applications, and out-of-network provider requests
- Consult with Medical Directors when care does not meet criteria or medical policies
- Document clinical information completely, accurately, and timely
- Meet or exceed production and quality metrics
- Apply provider contracts, member contracts, authorization requirements, Milliman Care Guidelines, and medical policy
- Identify Clinical Program opportunities and refer members to appropriate healthcare programs
- Collaborate with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services
- Ensure utilization management decisions and timeliness standards comply with accreditation and regulatory requirements
- Participate in quality improvement activities, process studies, and projects
Requirements:
- 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
- Experience working in the health plan industry
- Ability to work Monday through Friday, 8:00 AM to 5:00 PM Pacific Time
- Must reside in one of the listed hiring states, subject to role or city limitations
Benefits:
- Medical, vision, and dental coverage with low employee premiums
- Voluntary benefits, including pet insurance
- Life and disability insurance
- Retirement programs, including a 401K employer match
- Pension plan vested after 3 years of service
- Wellness incentives and mental well-being resources, including counseling, stress management, and mindfulness programs
- Generous paid time off
- Tuition assistance for undergraduate and graduate degrees
- Employee recognition program
- Commuter perks
- Free convenient on-site parking
- Subsidized on-campus cafes
- On-site health and wellness activities
- Fitness and well-being center with in-person and virtual workouts and nutritional counseling
