Utilization Review Clinician

This is a fully remote position, open to applicants in Alaska, +26 more states.

📋 Description

• Assess clinical requests from healthcare providers to determine if the care is medically suitable and complies with established criteria and protocols.

• Perform inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting medical necessity evaluations.

• Evaluate the medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and requests from out-of-network providers.

• Collaborate with Medical Directors when requested care does not align with applicable criteria or policies.

• Accurately document clinical information in a complete and timely manner.

• Achieve or surpass productivity and quality benchmarks.

• Stay informed about provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and clinical criteria.

• Identify opportunities to engage members with suitable Clinical Programs.

• Work together with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services teams.

• Ensure that Utilization Management decisions and turnaround times meet accreditation and regulatory standards.

• Contribute to the Plan’s Quality Program through quality enhancement initiatives, programs, processes, studies, and projects.

⛳️ Requirements

• A Bachelor's degree or 4 years of relevant work experience (Required).

• Current state licensure as a Registered Nurse (Required).

• WA or Compact RN license (Preferred).

• 3 years of clinical experience (Required).

• Experience in Utilization Review (Preferred).

• Background in the health plan industry (Preferred).

• Availability to work Monday through Friday or Tuesday through Saturday, 8:00 a.m. to 5:00 p.m. Pacific Time.

• Proficient in keyboarding and able to communicate clearly and effectively in person and over the telephone.

• Capability to perform sedentary work and occasionally apply up to 10 lbs. of force.

🏝️ Benefits

• Medical, vision, and dental insurance with low employee premiums.

• Optional benefits, including pet insurance.

• Life and disability insurance coverage.

• Retirement plans, featuring a 401K employer match and a pension plan that vests after 3 years of service.

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

• Generous paid time off policy.

• Tuition assistance for both undergraduate and graduate programs.

• Employee recognition initiatives.

• Commuter benefits.

• Complimentary convenient on-site parking.

• Subsidized on-campus dining options.

• On-site health and wellness activities.

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