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Director, Clinical Operations

2 months ago

Arlington, Virginia, United States Evolent Health Full time
About the Role

Evolent Health is seeking a highly skilled Director, Utilization Management to join our team. As a key member of our clinical operations team, you will be responsible for leading utilization management activities, ensuring delivery on clinical excellence, performance guarantees, and efficiencies for our members, providers, and customers.

Key Responsibilities
  • Lead utilization management activities, including design, implementation, and oversight of operations.
  • Monitor all activities related to clinical review, developing processes where indicated with direct oversight of centralized telephonic review process.
  • Partner with leadership to mentor staff, jointly developing goals, objectives, and defining major roles.
  • Responsible for achieving targeted utilization management results, monitoring and reporting resources, implementing initiatives, and educational processes.
  • Develop and adopt best practice methodologies and training programs for utilization management tools and techniques.
  • Collaborate with IT and Analytics teams for the development of required utilization management monitoring, initiatives, patient engagement, and other outcomes initiatives.
  • Collaborate with other functional areas that interface with the utilization management department, including claims, appeals, product, network development, and care management.
  • Provide appropriate and timely management of complex clinical issues.
  • Mentor and support ongoing training and development of staff.
  • Promote a positive work environment by providing timely, specific, and constructive performance feedback.
Requirements
  • Active clinical license such as Registered Nurse (RN), Physical/Occupational/Speech/Radiation Therapist, or Chiro, Pharmacist.
  • Working knowledge of utilization management activities such as prior authorization, concurrent review, intake, appeals, and grievances.
  • Five to seven years of progressive experience in utilization management.
  • Bachelor's Degree in Nursing or related healthcare field (with Bachelor's/Master's Degree in Business Administration/Hospital Administration/Public Health).
About Evolent Health

Evolent Health partners with health plans and providers to achieve better outcomes for people with complex and costly health conditions. 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.

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.