Clinical Reviewer, Nurse

Your 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 Youll Be Doing: Performs utilization review of outpatient procedures and ancillary services. Fulfills on call requirements for selected clients as scheduled. Determines medical necessity and appropriateness of services using clinical review criteria. Accurately documents all review determinations and contacts providers and members according to established timeframes. Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director. Appropriately identifies and refers quality issues to UM Leadership. Appropriately identifies potential cases for Care Management programs. Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum. Performs accurate data entry. Communicates appropriate information to other staff members as necessary/required. Participates in continuing education initiatives. Collaborates with Claims, Quality Management and Provider Relations Departments as requested. Availability on some weekends and holidays may be required. Performs other duties as assigned. The Experience Youll Need (Required): Registered Nurse or Licensed Practical/Vocational Nurse with a current, unrestricted license. High School Diploma or equivalent required. Minimum of three years of direct clinical patient care. Minimum of one year of experience with medical management activities in a managed care environment. Schedule: MondayFriday, 9:00 AM6:00 PM PST, with weekend and holiday rotation required. Finishing Touches (Preferred): Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual). UM Experience. Strong interpersonal, oral and written communication skills. Possess basic computer skills. Identity and Technical Requirements: Submission of a government issued photo ID and identity verification during interviews. Completion of a comprehensive background check, in?person I?9 verification, and may be subject to drug screening prior to employment. Artificial intelligence tools during interviews are prohibited. High speed internet over 10?Mbps is required for all employees. Call center employees must be able 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 recruiting@evolent.com for further assistance. The expected base salary/wage range for this position is $32$37/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. Don't 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 #J-18808-Ljbffr