Assistant Medical Director – Utilization Review

This is a fully remote position, open to applicants in Washington.

📋 Description

• Make determinations regarding benefit coverage based on medical necessity and contractual language.

• Evaluate clinical documentation in accordance with medical policy criteria, guidelines, and member contracts.

• Assist in clinical programs, including disease management and case management.

• Facilitate reviews for pre-service, post-service, concurrent facility-based care, and transitions between various levels of care.

• Render final coverage decisions based on medical necessity, investigational status, contractual exclusions, or network structure.

• Utilize clinical expertise to inform claims review decisions that involve level of care, pricing, complexity assessment, dependent disability status, and by-report procedure payment determinations.

• Engage in peer-to-peer discussions with external physicians and providers regarding denial decisions and gather additional clinical history.

• Collaborate with nursing and clinical staff to discuss care options for members enrolled in clinical programs.

• Contribute to the development, annual review, and approval of company medical review criteria through the Premera Medical Policy Committee.

• Aid in the ongoing education of clinicians involved in medical review processes.

• Offer professional consultation to Premera Blue Cross and contracted practitioners/facilities.

• Be involved in the Inter-Rater Review process to ensure consistency in clinical decision-making.

• Adhere to all applicable federal, state, and accreditation regulations and standards.

• Engage in continuing education and participate in ongoing training and educational opportunities.

⛳️ Requirements

• A valid physician license with an MD or DO degree.

• Unrestricted licensure in Washington state or an administrative license, or the ability to obtain it within 90 days.

• A minimum of five (5) years of clinical experience.

• Current board certification from the American Board of Medical Specialties, American Osteopathic Association, or another recognized organization acceptable to Premera (Preferred).

• Prior experience in conducting medical necessity and clinical reviews within a health plan environment (Preferred).

• Familiarity with clinical criteria sets and pathways, such as MCG (Milliman Care Guidelines), InterQual, or similar (Preferred).

• Knowledge of CPT, ICD, HCPC code sets, and RBRVS pricing concepts (Preferred).

• Ability to work five days a week, including 1–2 Saturdays each month.

• Must be able to operate on Pacific Standard Time (PST).

🏝️ Benefits

• Comprehensive medical, vision, and dental coverage with minimal employee premiums.

• Optional benefit offerings, such as pet insurance.

• Life and disability insurance options.

• Retirement plans, including a 401K employer match and a pension plan that vests after three years of service.

• Wellness incentives that encompass mental well-being resources, counseling services, stress management programs, and mindfulness initiatives.

• Generous paid time off policy.

• Tuition assistance for both undergraduate and graduate degree programs.

• Employee recognition programs.

• Commuter benefits.

• Complimentary, convenient on-site parking.

• Subsidized on-campus dining options.

• On-site health and wellness events, coffee meet-ups, disaster preparedness fairs, and various other activities.

• Access to a fitness and well-being center offering both in-person and virtual workouts, along with nutritional counseling.