Clinical Reviewer, Nurse (Radiology)

Evolent

6d•$34 - $37•Remote

About The Position

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. Collaboration Opportunities: As a Clinical Reviewer, Nurse, you will routinely interact with leadership and management staff, other CR’s (Clinical Reviewers), providers, office staff and Field Medical Directors (FMDs).

Requirements

A current RN clinical license, active and in good standing, in your home state
Associate or Bachelors in Nursing (Must be a Registered Nurse)
Strong interpersonal and communication skills
Proficient computer skills; must be able to talk and type simultaneously
Must be able to work a minimum of 30 hours/week
Ability to work 3, 4 or 5 days a week
Start time must be 9am EST or later
Flexibility to choose length of shift (ex. 3 (10s) 4 (10s) or 5 (8s) – etc.)

Nice To Haves

5+ years clinical experience

Responsibilities

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.
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.