SpokaneRecruiter Since 2001
the smart solution for Spokane jobs

Utilization Review Nurse

Company: Premera Blue Cross
Location: Spokane
Posted on: January 15, 2020

Job Description:

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.

To better serve our customers, we're creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

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 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
  • Performs other duties as assigned.

    What you will bring:

    • Bachelor's degree or 4 years' work experience
    • Current State licensure as a registered nurse or behavioral health clinician where licensing is required by State law
    • 3 years of clinical experience.
    • CPHM (Certified Professional Health Management) certification, or obtain certification within 36 months of the date of hire
    • Utilization Management experience (Preferred)
    • Experience working in the health plan industry.


      • #LI-EK1


        What we offer

        • Medical, vision and dental coverage
        • Life and disability insurance
        • Retirement programs (401K employer match and pension plan)
        • Wellness incentives, onsite services, a discount program and more
        • Tuition assistance for undergraduate and graduate degrees
        • Generous Paid Time Off to reenergize
        • Free parking

          Equal employment opportunity/affirmative action:Premera is an equal opportunity/affirmative action 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.

Keywords: Premera Blue Cross, Spokane , Utilization Review Nurse, Healthcare , Spokane, Washington

Click here to apply!

Didn't find what you're looking for? Search again!

I'm looking for
in category

Other Healthcare Jobs

Physician / Psychiatry - Geriatric / Washington / Permanent / Psychiat
Description: Facilities are IP - SNFs, ALFs or rehab. Patient base is primarily geriatrics with some adults. Treatable conditions: dementia,
Company: Confidential
Location: Spokane
Posted on: 01/18/2020

Description: SNF, 2 years experience required, 1/20-4/18. 8 hr NOC shift.LICENSED PRACTICAL NURSE - LPN - SKILLED NURSING FACILITY--CareerStaff Unlimited is--hiring a qualified Licensed Practical Nurse for a full-time, (more...)
Company: CareerStaff Unlimited
Location: Spokane
Posted on: 01/18/2020

Travel RN - Registered Nurse: ICU
Description: Our client in Spokane, WA has travel nursing position for an RN with current ICU experience.The ideal candidate must have at least 2 years of nursing experience, with active RN license and BLS and/or (more...)
Company: GO Healthcare Staffing
Location: Spokane
Posted on: 01/18/2020

NAC Sunshine Health and Rehab LLC
Description: Sunshine Health and Rehab has served the Spokane community for almost 70 years, providing exceptional long term and acute care services for adults in need. The facility is 5 star rated by the Centers (more...)
Company: Sunshine Health Facilities
Location: Spokane
Posted on: 01/18/2020

Travel Speech Therapist/SLP, San Diego, CA
Description: Travel Speech Therapist/SLP San Diego, CALocation: San Diego, CAStart Date: 1/14/2020Shift Details: 8H Days 7:00 AM-3:00 PM 40 hours per weekLength: 13 weeksApply for specific
Company: Triage Staffing
Location: Spokane
Posted on: 01/18/2020

Ultrasound Technologist - Nights - Spokane , WA
Description: FlexCare is a nationwide leader in the staffing of travel nurses and clinicians. With access to thousands
Company: FlexCare Medical Staffing
Location: Spokane
Posted on: 01/18/2020

Travel Med - Surg RN
Description: NurseStat is looking for a Travel Med - Surg RN in Spokane, WA.This is a 13 week assignment scheduled to start on 2/4/2020 and run through 5/2/2020.Shift: Nights. Possible on calls and weekends.You must (more...)
Company: AHS NurseStat
Location: Spokane
Posted on: 01/18/2020

Travel Nurse Medical Surgical - Med Surg RN
Description: Nationwide Travel Nurse Jobs - Medical Surgical RN Are you looking for a new nursing job Would you like to spend the season somewhere you've never been Hospitals nationwide are looking for qualified (more...)
Company: HealthCare Travelers
Location: Spokane
Posted on: 01/18/2020

Travel Telemetry RN needed
Description: TaleMed is searching for Med/Tele RNs to fill
Company: TaleMed
Location: Spokane
Posted on: 01/18/2020

Nurse Mgr - Mother Baby
Description: The reasons to work at MultiCare are as unique as the people who do. --Join us for the professional challenges you seek. --In the settings you prefer. --With schedules that fit your life. --Learn more (more...)
Company: MultiCare
Location: Spokane
Posted on: 01/18/2020

Log In or Create An Account

Get the latest Washington jobs by following @recnetWA on Twitter!

Spokane RSS job feeds