Clinical Reviewer, Nurse

Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of the 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 You'll Be Doing:

The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed within the RN/LVN/LPN scope of practice, under the Medical Director's direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum and working in concert with the health care delivery team to maintain high-quality, cost-effective care delivery.

Tasks include:

• Perform pre-certification utilization reviews of Oncology treatment requests
• Determines medical necessity and appropriateness of services using clinical review criteria
• Accurately documents all review rationales and determinations
• 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
• Collaborates with physicians and other providers to facilitate the 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
• Availability on some weekends and holidays may be required
• Performs other duties as assigned

The Experience You'll 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 (acute, inpatient, or critical care setting); strongly prefer direct Oncology experience
• Strong computer skills, including MS Office Suite
• Strong interpersonal, oral, and written communication skills
• Availability for weekend holiday rotation

Finishing Touches (Preferred):

• Experience with clinical decision-making criteria sets (i.e., Milliman, InterQual)
• Minimum of one year of experience with medical management activities in a managed care environment
• UM/UR experience
• Clinical experience in Oncology, ICU, ED, or other critical care environment
• Remote work experience

Technical 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.

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.