Clinical Reviewer, Nurse

Evolent

3d•Remote

About The Position

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. 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.

Requirements

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
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
High speed internet over 10 Mbps and, specifically for all call center employees, the ability to plug in directly to the home internet router.

Nice To Haves

5+ years clinical experience is preferred

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.
Renders authorization approval based on established clinical criteria; escalates to a Field Medical Director (FMD) if authorization cannot be approved during initial review.
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.