Assistant Medical Director – Utilization Review

Premera Blue Cross

. Provide benefit coverage determinations based on medical necessity and contract language .

Posted 9/24/2026full-timeRemote • Washington • United StatesLead💰 $214,500 - $386,100 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in medical necessity determinations, clinical documentation review, and compliance with healthcare regulations. Proficient in supporting clinical programs and conducting peer-to-peer discussions with healthcare providers.

Highest-signal resume keywords

Physician License (MD or DO)Clinical Experience (5 Years)Medical Necessity ReviewClinical Criteria Sets (MCG, InterQual)CPT, ICD, HCPC Code Sets

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Clinical Documentation ReviewMedical Policy CriteriaClaims Review DecisionsComplexity AssessmentDependent Disability Status Evaluation

Soft Skills

Consultation SkillsCollaboration with Clinical StaffPeer-to-Peer Discussion

Certifications & Qualifications

Board Certification (American Board of Medical Specialties or American Osteopathic Association)

Industry Keywords

Health Plan SettingAccreditation RegulationsContinuing EducationInter-Rater Review ProcessPacific Standard Time (PST)

About the role

Key responsibilities & impact

Provide benefit coverage determinations based on medical necessity and contract language
Review clinical documentation using medical policy criteria, guidelines, and member contracts
Support clinical programs including disease management and case management
Support pre-service, post-service, concurrent facility-based care, and transitions between levels of care reviews
Make final coverage decisions based on medical necessity, investigational status, contractual exclusions, or network structure
Use clinical expertise to support claims review decisions involving level of care, pricing, complexity assessment, dependent disability status, and by-report procedure payment determinations
Support peer-to-peer discussions with external physicians and providers regarding denial determinations and collect additional clinical history
Consult with nursing and clinical staff regarding care options for members in clinical programs
Participate in development, annual review, and approval of company medical review criteria through the Premera Medical Policy Committee
Support ongoing education for clinicians involved in medical review
Provide professional consultation to Premera Blue Cross and contracted practitioners/facilities
Participate in the Inter-Rater Review process to ensure consistency in clinical decision-making
Comply with applicable federal, state, and accreditation regulations and standards
Complete continuing education and participate in ongoing education and training

Requirements

What you’ll need

Physician 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, American Osteopathic Association, or another 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)
Ability to work 5 days a week, including 1–2 Saturdays per month
Ability to operate on Pacific Standard Time (PST)

Benefits

Comp & perks

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 pension plan vested after 3 years of service
Wellness incentives, including mental well-being resources, counseling services, stress management programs, and mindfulness programs
Generous paid time off
Tuition assistance for undergraduate and graduate degrees
Employee recognition program
Commuter perks
Free convenient on-site parking
Subsidized on-campus cafes
On-site health and wellness events, coffee connects, disaster preparedness fairs, and other activities
Fitness and well-being center with in-person and virtual workouts and nutritional counseling