Utilization Review Clinician

Premera Blue Cross

. Evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols .

Posted 9/24/2026full-timeRemote • United StatesMid-LevelSenior💰 $80,200 - $125,600 per yearWebsite

Core Competencies

Role fit

Core Competencies

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Demonstrates expertise in clinical evaluation and medical necessity reviews, ensuring compliance with established criteria and protocols. Proficient in collaborating with healthcare teams and maintaining knowledge of clinical guidelines and regulatory requirements.

Highest-signal resume keywords

Registered Nurse LicenseClinical ExperienceUtilization ReviewInterQual GuidelinesHealth Plan Industry Experience

ATS Keywords

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Applicant Tracking System Keywords

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Hard Skills

Medical Necessity ReviewClinical DocumentationInpatient Admissions AssessmentOutpatient Services AssessmentBenefit AdvisoryPrior AuthorizationRetrospective ReviewTreatment-Setting ReviewQuality Improvement InitiativesProductivity Standards

Soft Skills

Clear CommunicationCollaborationCustomer Service

Certifications & Qualifications

Bachelor's DegreeCurrent State Licensure as a Registered Nurse

Industry Keywords

Utilization ManagementAccreditation RequirementsClinical ProgramsProvider ContractsAuthorization Requirements

About the role

Key responsibilities & impact

Evaluate clinical requests from providers to determine whether care is medically appropriate and aligned with established criteria and protocols
Conduct inpatient, concurrent, benefit advisory/prior authorization, retrospective, out-of-network, and treatment-setting medical necessity reviews
Assess medical necessity of inpatient admissions, outpatient services and procedures, benefit applications, and out-of-network provider requests
Consult with Medical Directors when requested care does not meet applicable criteria or policies
Document clinical information completely, accurately, and on time
Meet or exceed productivity and quality standards
Maintain knowledge of provider and member contracts, authorization requirements, InterQual Guidelines, medical policies, and clinical criteria
Identify opportunities to connect members with appropriate Clinical Programs
Collaborate with Customer Service/Claims Operations, Sales and Marketing, and Health Care Services
Ensure Utilization Management decisions and turnaround times comply with accreditation and regulatory requirements
Support the Plan’s Quality Program through quality improvement initiatives, programs, processes, studies, and projects

Requirements

What you’ll need

Bachelor's degree or 4 years’ work experience (Required)
Current state licensure as a Registered Nurse (Required)
WA or Compact RN license (Preferred)
3 years of clinical experience (Required)
Utilization Review experience (Preferred)
Experience working in the health plan industry (Preferred)
Ability to work Monday through Friday or Tuesday through Saturday, 8:00 a.m. to 5:00 p.m. Pacific Time
Ability to keyboard and communicate clearly and understandably in person and over the telephone
Ability to perform sedentary work and occasionally exert up to 10 lbs. of force

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 activities
Fitness and well-being center with in-person and virtual workouts and nutritional counseling