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Our purpose, to improve customers’ lives by making healthcare work better, is far from ordinary. And so are our employees. Working at Premera means you have the opportunity to drive real change by transforming healthcare.

To better serve our customers, we’re creating a culture that promotes employee growth, collaborative innovation, and inspired leadership. We are committed to creating an environment where employees can do their best work and where best-in-class talent comes, stays, and thrives!

As an Assistant Medical Director at Premera, you will provide benefit coverage determinations based on medical necessity and contract language for health plan members, including review of clinical documentation using medical policy criteria, guidelines, and member contracts.

What you will do:

• Support clinical review activities including all of the following: pre-service, post-service, concurrent facility-based care, and transitions between levels of care. Act as the final decision maker for coverage decisions based on medical necessity, investigational status, other contractual exclusion or network structure.
• Use clinical expertise to support claims review decisions, including level of care, pricing and complexity assessment, dependent disability status and by report procedure payment determinations.
• Support the peer-to-peer discussion process by communicating with external physicians and providers about denial determination and collect additional clinical history in a given case.
• Consult with nursing and other clinical staff to assess and explore care options for members enrolled in clinical programs such as disease management, case management and care transition management.
• Participate in the development, annual review, and approval of company medical review criteria as a member of the Premera Medical Policy Committee.
• Leverage clinical knowledge and expertise to support ongoing education for all clinicians involved in medical review.
• Provide professional advisement to all requests for consultation from within Premera Blue Cross and with contracted practitioners/ facilities.
• Participate in Inter-Rater Review process to ensure consistency in clinical decision making.
• Understand and abide by applicable federal, state, and accreditation regulations and standards. Complete all professional continuing education requirements and participate in on-going education/ training as appropriate.

What you will bring:

• 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. (Preferred)
• 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)

What we offer:

• 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

Equal employment opportunity/affirmative action:

Premera is an equal opportunity/affirmative action employer. Premera seeks to attract and retain the most qualified individuals without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, gender or gender identity, sexual orientation, genetic information or any other protected characteristic under applicable law.

If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at careers@premera.com or via phone at 425-918-4785.