Appeals Nurse

divh2Evolent Health Care Opportunity/h2pEvolent partners with health plans and providers to achieve better outcomes for people with complex health conditions. We seek to connect fragmented health care and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, flexibility, and autonomy. Diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture./ppWhat Youll Be Doing: The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve./ppCollaboration Opportunities: The Specialty Appeal nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments./ppWhat You Will Be Doing:/pulliPractices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures./liliDocuments communications with medical office staff and/or MD provider as required./liliInterfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews./liliProvides optimum customer service through professional and accurate communication while maintaining accreditation and health plans required timeframes./liliRefers cases to appropriate internal reviewers according to the business needs of the particular health plan./liliReviews requests for Urgent appeals compared to expedited criteria for downgrade to Standard processing, documenting accordingly./liliWorks closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals./liliOther duties as assigned./li/ulpQualifications Required and Preferred:/pulli1-3 years experience as an RN - Required/liliMinimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment - Required/liliAble to work in a rotation to work 10:30am to 7pm CST (which includes 30-minute unpaid lunch break) 3 days/week, to meet the business needs of nurses providing coverage until 7:00pm CST. - Required/liliMust be able to exercise independent and sound judgment in clinical decision making. - Preferred/liliAble to navigate through internal and external computer systems. Working knowledge of Microsoft Office Product Suit - Preferred/liliStrong organizational and effective time management skills; demonstrated ability to manage multiple priorities. Preferred/liliOutstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally, including strong written and verbal communication skills. - Preferred/li/ulpTechnical 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. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations./ppEvolent 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./ppIf you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance./ppThe expected base salary/wage range for this position is $37- $42/hr. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. 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. Dont see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit/p/div