Utilization Review Nurse
WFA Digital Insight
The demand for skilled Utilization Review Nurses has grown significantly in the remote job market, with a 25% increase in openings over the past year. As healthcare continues to evolve, professionals with strong clinical knowledge and critical thinking skills are in high demand. Premera Blue Cross stands out for its commitment to employee growth and innovation, making it an attractive choice for those looking to drive real change in the industry. With the rise of remote work, candidates should be prepared to demonstrate their ability to work independently and collaboratively in a virtual environment.
Job Description
About the Role
The Utilization Review Nurse plays a crucial role in ensuring that healthcare services are delivered in a cost-effective and medically necessary manner. As a key member of the Premera Blue Cross team, you will be responsible for performing prospective reviews of clinical requests from providers, applying your clinical knowledge and critical thinking skills to assess the medical necessity of outpatient services and procedures. You will work closely with Medical Directors and other departments to drive appropriate care decisions and collaborate with internal teams to ensure consistent work processes and procedural application of clinical criteria.The role entails a deep understanding of the Plan's provider contracts, member contracts, authorization requirements, and clinical criteria, including InterQual care guidelines and medical policy. You will be expected to maintain a thorough understanding of accreditation and regulatory requirements, ensuring that these requirements are accurately followed and Utilization Management decision determinations and timeliness standards are within compliance.
What You Will Do
- Perform medical necessity reviews, including benefits advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews
- Consult with Medical Directors when care does not meet applicable criteria or medical policies
- Document clinical information completely, accurately, and in a timely manner
- Meet or exceed production and quality metrics
- Maintain a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements, and clinical criteria
- Identify Clinical Program opportunities and refer members to the appropriate healthcare program
- Collaborate, educate, and consult with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services
- Support the Plan's Quality Program by identifying and participating in quality improvement activities
- Perform other duties as assigned
What We Are Looking For
- Bachelor's degree or 4 years of work experience
- Current State licensure as a registered nurse
- 3 years of clinical experience
- Utilization Management experience
- Experience working in the health plan industry
- Strong clinical knowledge and critical thinking skills
- Ability to work independently and collaboratively in a virtual environment
Nice to Have
- Experience with InterQual care guidelines and medical policy
- Knowledge of accreditation and regulatory requirements
- Experience with quality improvement initiatives
Benefits and Perks
- Competitive salary and benefits package
- Opportunity to work with a leading healthcare company
- Collaborative and dynamic work environment
- Professional development and growth opportunities
- Remote work flexibility
- Access to cutting-edge technology and tools
- Comprehensive health and wellness programs
How to Stand Out
- Tip: Highlight your experience with Utilization Management and clinical knowledge in your application and during the interview process.
- Be prepared to provide specific examples of how you have applied your critical thinking skills in a clinical setting.
- Familiarize yourself with InterQual care guidelines and medical policy to demonstrate your understanding of the role's requirements.
- Showcase your ability to work independently and collaboratively in a virtual environment by highlighting your experience with remote work and team collaboration tools.
- Prepare to discuss your experience with quality improvement initiatives and how you have contributed to quality programs in your previous roles.
- Research Premera Blue Cross's company culture and values to demonstrate your understanding of the company's mission and vision.
This is a remote position listed on WFA Digital, the platform for professionals who work from anywhere. Browse more remote jobs across all categories.