Mountlake Terrace, WA5 days ago
_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. 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.