Clinical Reviewer, Nurse - 9am -6pm PST

Evolent; Jackson (MS); Remote; USD 60,000 - 80,000; Full time

Job summary

A healthcare partner organization is seeking a Nurse Reviewer to perform precertification and prior approvals. This role requires a registered nurse or licensed practical/vocational nurse to utilize independent judgment and collaborate with healthcare teams. Candidates must have three years of direct clinical experience and document review determinations. This position offers flexible work arrangements and a competitive salary of $32-$37/hr.

Benefits

Comprehensive health insurance

Work/life balance

Flexible working arrangements

Qualifications

• Registered Nurse or Licensed Practical/Vocational Nurse with a current, unrestricted license.
• Minimum of three years of direct clinical patient care is required.
• Minimum of one year of experience with medical management activities in a managed care environment is required.

Responsibilities

• Perform utilization review of outpatient procedures and ancillary services.
• Determine medical necessity and appropriateness of services using clinical review criteria.
• Communicate appropriate information to other staff members as necessary.

Skills

Clinical decision-making

Interpersonal communication

Documentation skills

Basic computer skills

Education

High School Diploma or equivalent

Registered Nurse license

Job description

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 You’ll Be Doing:

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 You’ll Be Doing:

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

What You’ll 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 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

• Minimum of one year of experience with medical management activities in a managed care environment

• Schedule: Monday–Friday, 9:00 AM–6:00 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

To comply with HIPAA security standards (45 C.F.R. sec. 164.308 (a) (3)), identity verification may be required as part of the application process. This is collected for compliance and security purposes and only reviewed if an applicant advances to the final interview state. Reasonable accommodations are available upon request.

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 [e-mail] 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.

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