Clinical Review Rep

Join Our Team: Do Meaningful Work and Improve People’s Lives 

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 a result of these efforts we are proud to share that Forbes ranked Premera among America’s 2023 Best Midsize Employers and America's 2023 Best Employers By State.

Learn how Premera supports our members, customers and the communities that we serve through our Healthsource blog:  https://healthsource.premera.com.

The Clinical Review Representative (CRR) works independently performing intake of inpatient and outpatient service requests and provides information to external customers and medical professionals as related to medical services inquiries. They are responsible for managing all lines of business. The CRR is a self-starter that applies their understanding of a variety of complex lines of business (e.g., national accounts, self-insured, fully-insured, etc) when responding to both providers and members regarding their clinical review questions and requests.

What you will do:

• Applies knowledge of various applications within the Facets claims payment system (e.g., customer service, benefits, eligibility, prospective UM) to manage incoming calls from hospitals, providers, and members related to requested services and to resolve inquiries.
• Serves as a resource for the customer service representatives for medical inquiries that cannot be resolved by Operations; triages and consults with clinical staff as appropriate.
• Utilizes various applications (e.g., Facets, CCA, and Express Scripts) to process and load incoming information for inpatient notifications, discharges, pre-service requests, certifications, referrals, and pharmacy requests.
• Applies their understanding of regulatory and accreditation standards related to the role.
• Follows clinical criteria as scripted, utilizing knowledge of medical terminology to collect data, conduct initial case screening and process requests. Review and collection of data do not require any clinical evaluation or clinical interpretation of information.
• Handles specialized account needs, and complex inpatient and outpatient account specific needs (e.g., customized benefit requests, overlapping coverage issues, special benefit handling).
• Identifies system and provider issues and trends; recommends changes to processes and takes the lead in initiating improvements (e.g., team meeting discussions, creates job aides, initiation of procedure changes).
• Assists in training and supporting new team members.

What you will bring:

• At least one (1) year of experience in a customer service-oriented environment.
• Associate degree in a medically related field (Preferred).
• Experience with Express Scripts system (Preferred).
• Demonstrated effective written and verbal skills with the ability to communicate professionally.
• Demonstrated effective telephone skills.
• Effective time management, organization and prioritization skills.
• Demonstrated ability to handle stressful situations, work in a high production environment and follow through on assigned tasks.
• Ability to work independently and as a member of a team and to work flexible hours to meet specific work demands.
• Intermediate skills with Microsoft Office Outlook, Word, Office Communicator, Live Meeting; familiarity with Excel.
• Basic knowledge of medical terminology.

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.

Premera is hiring in the following states, with some limitations based on role or city: Alaska, Arizona, Arkansas, California, Colorado, Florida, Georgia, Idaho, Iowa, Kansas, Kentucky, Maine, Michigan, Minnesota, Missouri, Montana, Nevada, New Hampshire, New Mexico, North Carolina, Oklahoma, Oregon, South Carolina, South Dakota, Tennessee, Texas, Utah, Washington, Wisconsin.

The pay for this role will vary based on a range of factors including, but not limited to, a candidate’s geographic location, market conditions, and specific skills and experience.

National Salary Range:

National Plus Salary Range:

*National Plus salary range is used in higher cost of labor markets including Western Washington and Alaska.