Premera Blue Cross Director of Clinical Review (Utilization Review) in Mountlake Terrace, Washington

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 the Director of Clinical Reviewat Premera, you be responsible for the development and implementation of the utilization management strategy and goals and the oversight of utilization management operations. The Director is accountable for ensuring effective integration and continuous improvement of processes and systems to meet Premera's current and future business needs and goals. Functional and budgetary areas of accountability include prospective and retrospective clinical review, concurrent review, clinical appeals and the clinical call center.

What you’ll do

  • Develop and lead clinical appeals and utilization management strategy and plan in accordance with the company's mission and strategic goals, federal and state law and regulations, and accreditation standards. Lead the planning of resources and systems to support implementation of Premera's clinical appeals and utilization management strategy and operations.
  • Lead and execute clinical appeals and utilization management strategy to achieve department and company goals. Develop and maintain a culture of continuous improvement that positively contributes to the achievement of the Healthcare Services Division and Premera's goals.
  • Represent department, programs and clinical priorities with internal executive management and key external stakeholders. Act as the liaison to third party organizations support Premera's utilization management activities.
  • Provide input and direct support to development and ongoing measurement of operational metrics and reports Collect, analyze, maintain and report data on the utilization of medical services, department results and use of resource.
  • Lead communications, educate, and train department managers and associates across the company as to the utilization management plan and their respective responsibilities relative to the plan.
  • Attract, develop and retain a skilled workforce and provide development opportunities to meet the evolving needs of the organization. Organize and integrate the work efforts of multiple teams to achieve organizational efficiency and effectiveness.

What you’ll bring

  • Bachelor's degree in a business or healthcare related field or four (4) years’ of closely related work experience is required. Bachelor's degree in nursing or an advanced degree (MBA, MHA or other master's degree) is preferred.
  • Seven (7) years of health plan industry experience.
  • Five (5) years of progressive management experience including experience managing multifunctional teams in multiple locations.
  • Experience with Blue Cross and/or Blue Shield plans and/ or experience managing utilization management programs is preferred
  • Experience in continuous process improvement (e.g. Lean or Six Sigma) is preferred.

What we offer

Premera is proud to offer a comprehensive benefits package including:

  • 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


Job Title: Director of Clinical Review (Utilization Review)

Job ID: 11311

Location: Mountlake Terrace, WA

Full/Part Time: Full-Time

Regular/Temporary: Regular

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, national origin, gender or gender identity, sexual orientation, age, genetic information, disability or veteran status. All staff of Premera and its subsidiary companies must demonstrate the legal right to work in the United States. Premera is an E-Verify employer.