Role Description We have an opening for a Utilization Review Nurse! The Utilization Review Nurse performs prospective review (benefit advisory/prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments to ensure appropriate cost-effective care by applying their clinical knowledge and critical thinking skills.

• Performs medical necessity review that includes inpatient review, concurrent review, benefits advisory/prior authorization, retrospective, out of network, and appropriateness of treatment setting reviews.
• 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.
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare program.
• Collaborates, educates, and consults with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services.
• Maintains a thorough understanding of accreditation and regulatory requirements.
• Supports the Plan's Quality Program by identifying and participating in quality improvement activities.
• Performs other duties as assigned.

Qualifications

• Bachelor's degree or 4 years’ work experience.
• Current State licensure as a registered nurse or behavioral health clinician where licensing is required by State law.
• 3 years of clinical experience.
• CPHM (Certified Professional Health Management) certification, or obtain certification within 36 months of the date of hire.
• Utilization Management experience (Preferred).
• Experience working in the health plan industry.

Requirements

• Deeper expertise in utilization management (prospective, concurrent, and retrospective review) using evidence-based criteria and medical policy.
• Stronger cross-functional collaboration and clinical influence through partnership with Medical Directors and internal teams.
• Growth in regulatory/accreditation and quality improvement proficiency.

Benefits

• Medical, vision, and dental coverage with low employee premiums.
• Voluntary benefit offerings, including pet insurance.
• Life and disability insurance.
• Retirement programs, including a 401K employer match and a pension plan vested after 3 years of service.
• Wellness incentives and mental well-being resources.
• Generous paid time off.
• Tuition assistance for both undergraduate and graduate degrees.
• Employee recognition program.
• Flexible on-campus model for hybrid employees.
• Commuter perks and free on-site parking.
• Subsidized on-campus cafes.
• Engaging on-site activities such as health and wellness events.
• Complementary fitness & well-being center.