Manager Clinical Review - FEP

Workforce Classification:

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.

Premera is committed to being a workplace where people feel empowered to grow, innovate, and lead with purpose. By investing in our employees and fostering a culture of collaboration and continuous development, we’re able to better serve our customers. It’s this commitment that has earned us recognition as one of the best companies to work for. Learn more about our recent awards and recognitions as a greatest workplace.

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

The Manager of Clinical Review - FEP is a leadership role supporting Premera’s Federal Employee Program and overseeing utilization management (UM) operations. In this role, you’ll lead clinical and support teams, shape UM strategy, and drive outcomes related to quality, member experience, and team performance. You’ll have autonomy, visibility into cross-functional initiatives, and the support of a collaborative leadership team. Key areas of accountability include prospective and retrospective clinical review, concurrent review, clinical appeals, and the clinical call center.

What you’ll do:

•  Participate in development of clinical review strategy and plan in accordance with company's mission and strategic goals, federal and state law and regulations, and accreditation standards.
• Manage and develop teams consisting of diverse clinical and related positions and skill sets. Promote staff development to support professional growth and operational effectiveness. Provide timely feedback and coaching on a regular basis to ensure continuous development to meet current and future needs of the business.
• Represent department, programs and clinical priorities with senior management and key external stakeholders.
• Support the allocation of resources and systems to support implementation of Premera's clinical review strategy and operations.
• Provide input and direct support to the development and ongoing measurement of operational metrics and reports.
• Coordinate work effort with Sr Manager, Director of Clinical Review and peers of multiple teams to achieve organizational efficiency and effectiveness.
• Collect, analyze, maintain and report data on the utilization of medical services, department results and resource use.
• Lead and maintain a culture of continuous improvement that positively contributes to the achievement of IHM's and Premera's goals.
• Lend business and/or clinical expertise to support business needs.
• Develop and manage department budget(s).
• Lead, support or participate in special projects as assigned.

What you’ll bring:

• Bachelor's degree in a business or healthcare related field or 4 years’ work experience. (Required)
• 1 year of health plan or relevant business experience. (Required)
• 2 years of progressive management experience including experience managing multifunctional teams in multiple locations. (Required)
• Current Washington licensed registered nurse, licensed mental health professional, licensed pharmacist highly preferred
• Experience managing utilization management/clinical review teams highly preferred
• Experience with Blue Cross and/or Blue Shield plans.
• Must be able to align to PST business hours, 8am - 5pm

Premera total rewards

Our comprehensive total rewards package provides support, resources, and opportunities to help employees thrive and grow. Our total rewards are more than a collection of perks, they're a reflection of our commitment to your health and well-being. We offer a broad array of rewards including physical, financial, emotional, and community benefits, including:

• 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, believe it or not, 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 y