Assistant Medical Director

Description: • Provide benefit coverage determinations based on medical necessity and contract language • Support clinical review activities including pre-service, post-service, concurrent facility-based care • Act as the final decision maker for coverage decisions • Use clinical expertise to support claims review decisions • Support peer-to-peer discussion process with external physicians • Consult with nursing and other clinical staff to assess care options • Participate in the development and annual review of company medical review criteria • Leverage clinical knowledge and expertise to support ongoing education for clinicians • Provide professional advisement for consultation requests • Participate in Inter-Rater Review process for consistency in clinical decision making • Understand and abide by federal, state, and accreditation regulations • Complete all professional continuing education requirements Requirements: • 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 • 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) Benefits: • 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 Apply Job!