Clinical Reviewer, Nurse
Evolent HealthYour Future Evolves Here
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.
Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.
Join Evolent for the mission. Stay for the culture.
What You’ll Be Doing:
As a Clinical Reviewer, Nurse you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients’ lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.
Essential Functions
• Functions in a clinical review capacity to evaluate all cases , which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Renders authorization approval based on established clinical criteria; escalates to a Field Medical Director (FMD) if authorization cannot be approved during initial review. Clinical Reviewers are supported by FMDs in the utilization management determination process.
• Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
• Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale, while providing optimum customer service through professional/accurate communication and maintaining NCQA and health plans required timeframes.
• Documents all communication with medical office staff and/or treating provider.
• Practices and maintains the principles of utilization management by adhering to policies and procedures.
• Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations, as well as, being audited to ensure guidelines are applied appropriately.
Required Qualifications
• Current, unrestricted state licensure as a Registered Nurse
• Associate or Bachelor's in nursing (Must be a Registered Nurse)
• Strong interpersonal and communication skills
• Proficient computer skills; must be able to talk and type simultaneously
• 5+ years clinical experience is preferred
• Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.
• No history of disciplinary or legal action by a state medical board
To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration.
Technical Requirements:
We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router.
Evolent is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access the information provided on this website, please contact recruitingteam@evolent.com for further assistance.
The expected base salary/wage range for this position is $36-40. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.