Care Coordinator - Clinical Appeals
The Care Coordinator - Clinical Appeals 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 get in this role:
- Play a key role in improving healthcare outcomes and ensuring the judicious use of resources.
- Join a team of professionals dedicated to ensuring the highest quality of care while managing utilization effectively.
- Influence critical decisions that impact patient care and organizational efficiency.
- Opportunities for ongoing learning and career development in the ever-changing field of healthcare.
What you'll 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 ensure compliance with applicable criteria, medical policy, member eligibility, benefits, and contracts.
- Consults with Medical Directors when care does not meet applicable criteria or medical policies.
- Documents clinical information completely, accurately, and in a timely manner.
- Meets or exceeds production and quality metrics.
- Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements and clinical criteria including Milliman Care Guidelines and medical policy.
- Identifies 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 criteria.
- Maintains 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 compliance.
- Supports the Plan's Quality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies and projects.
What you'll bring:
- 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
Premera total rewards
Our 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 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, just to name a few.
- Generous paid time off to reenergize.
- Looking for continuing education? We have tuition assistance for both undergraduate and graduate degrees.
- Employee recognition program to celebrate anniversaries, team accomplishments, and more.
For our hybrid employees, our 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.
- Our complementary fitness & well-being center offers both in-person and virtual workouts and nutritional counseling.
- Need a brain break? Challenge someone to a game of shuffleboard or ping pong while on campus.
Equal employment opportunity
Premera is an equal opportunity 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 careers@premera.com or via phone at 425-918-4785.
Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.
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: $78,000.00 - $122,200.00
National Plus Salary Range: $81,900.00 - $139,200.00
*National Plus salary range is 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.