Job Description
Description:
Provide benefit coverage determinations based on medical necessity and contract language
Support clinical review activities including pre-service, post-service, concurrent facility-based care
Act as the final decision maker for coverage decisions
Use clinical expertise to support claims review decisions
Support peer-to-peer discussion process with external physicians
Consult with nursing and other clinical staff to assess care options
Participate in the development and annual review of company medical review criteria
Leverage clinical knowledge and expertise to support ongoing education for clinicians
Provide professional advisement for consultation requests
Participate in Inter-Rater Review process for consistency in clinical decision making
Understand and abide by federal, state, and accreditation regulations
Complete all professional continuing education requirements
Requirements:
Physicians license with an MD or DO degree
Unrestricted Washington state licensure or administrative license or ability to obtain within 90 days
Five (5) years of clinical experience
Current board certification from the American Board of Medical Specialties, or the American Osteopathic Association or other recognized Association acceptable to Premera
Previous experience performing medical necessity and clinical reviews in a health plan setting (Preferred)
Prior use of clinical criteria sets and clinical pathways, such as MCG (Milliman Care Guidelines), Interqual® or others (Preferred)
Familiarity with CPT, ICD, HCPC code sets and RBRVS pricing concepts (Preferred)
Benefits:
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
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