Care Coordinator - Retrospective RN

Workforce Classification: Telecommuter Schedule: Monday through Friday, 8:00 AM to 5:00 PM Pacific Time. The Care Coordinator - Retrospective evaluates prospective reviews (benefit advisory/ prior authorization), admission, concurrent, and retrospective reviews across all lines of business and geographic regions to determine medical appropriateness of clinical requests from providers. The incumbent partners with Medical Directors and other Premera Departments such as FEP, National Account Liaisons, Health Care Services and Claims to ensure cost‑effective care by applying clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, benefit applications and provider out‑of‑network requests. What you will do: Perform medical necessity reviews that include inpatient review, concurrent review, benefit 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. 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 including Milliman Care Guidelines and medical policy. Identify Clinical Program opportunities and refer members to the appropriate healthcare program (e.g., case management, engagement team, and disease management). Collaborate, educate, and consult with Customer Service/Claims Operations, Sales and Marketing and Health Care Services to ensure consistent work processes and procedural application of clinical criteria. Maintain a thorough understanding of accreditation and regulatory requirements, and ensure these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance. Support the Plan's Quality Program: Identify and participate in quality improvement activities as it relates to internal programs, process studies and projects. What you will bring: Bachelor's degree or four (4) years’ work experience (Required) Current State Licensure as a registered nurse (Required) Three (3) years of clinical experience (Required) Utilization Management experience (Preferred) Experience working in the health plan industry (Preferred) What you will gain: Play a key role in improving healthcare outcomes and ensuring the judicious use of resources. Join a team of professionals dedicated to ensuring the highest quality of care while managing utilization effectively. Influence critical decisions that impact patient care and organizational efficiency. Opportunities for ongoing learning and career development in the ever‑changing field of healthcare. Physical Requirements: This is primarily a sedentary role which requires the ability to exert up to 10 lbs. of force occasionally and/or a negligible amount of force frequently or constantly to lift, carry, push, pull, or otherwise move objects, including the human body. The role requires the ability to use a keyboard and to communicate clearly and understandably in person and over the telephone. Premera Total Rewards Medical, vision, and dental coverage with low employee premiums. Voluntary benefit offerings, including pet insurance for paw parents. Life and disability insurance. Retirement programs, including a 401K employer match and a pension plan that is vested after 3 years of service. Wellness incentives with a wide range of mental well‑being resources for you and your dependents, including counseling services, stress management programs, and mindfulness programs. Generous paid time off to reenergize. Tuition assistance for both undergraduate and graduate degrees. Employee recognition program to celebrate anniversaries, team accomplishments, and more. Hybrid Employee Benefits Commuter perks make your trip to work less impactful on the environment and your wallet. Free convenient on‑site parking. Subsidized on‑campus cafes make lunchtime connections with colleagues fun and affordable. Participate in engaging on‑site activities such as health and wellness events, coffee connects, disaster preparedness fairs and more. Our complementary fitness & well‑being center offers both in‑person and virtual workouts and nutritional counseling. Challenge someone to a game of shuffleboard or ping‑pong while on campus. 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. Salary Range National Salary Range: $80,200.00 - $125,600.00 National Plus Salary Range: $84,200.00 - $143,100.00 Accommodation for Applicants If you need an accommodation to apply online for positions at Premera, please contact Premera Human Resources via email at View email address on click.appcast.io or via phone at View phone number on click.appcast.io. #J-18808-Ljbffr Premera