RN- Initial Clinical Reviewer, Musculoskeletal

Description

Your Future Evolves Here Evolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Evolenteers make a difference wherever they are, whether it is at a medical center, in the office, or while working from home across 48 states. We empower you to work from where you work best, which makes juggling careers, families, and social lives so much easier. Through our recognition programs, we also highlight employees who live our values, give back to our communities each year, and are champions for bringing their whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it. Why We’re Worth the Application:

• We continue to grow year over year.
• Recognized as a leader in driving important diversity, equity, and inclusion (DE&I) efforts .
• Achieved a 100% score two years in a row on the Human Rights Campaign's Corporate Equality Index recognizing us as a best place to work for LGBTQ+ equality.
• Named to Parity.org’s list of the best companies for women to advance for 3 years in a row (2020, 2021 and 2022).
• Continue to prioritize the employee experience and achieved a 90% overall engagement score on our employee survey in May 2022.
• Publish an annual DE&I report to share our progress on how we’re building an equitable workplace.

What You’ll Be Doing: Do you crave an exciting new job that allows you to use your years of clinical expertise while developing new skills and improving the lives of others? If so, then this is the fit for you. As an Initial Clinical Reviewer, you’ll use your clinical knowledge to provide evidence-based Musculoskeletal reviews for patient care. You will be a key member of the utilization management team and routinely interact with physicians, leadership, management staff and other Initial Clinical Reviewers (ICR’s). We provide you with all the computer equipment and training needed to be successful in this role. And the best part, you get to reap the benefits of a work-from-home role. If you are looking for a better work life balance, we offer that at Evolent. We offer part-time and full-time roles, so that you can choose a schedule that works best for you! Job Summary Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff. Initial clinical reviewers are supported by Physician clinical review staff (MDs) in the utilization management determination process. Schedule Options Core Business hours are 7a-7p CST, Monday-Friday, but hours are flexible

• Full-time- 30-40 hours
• Part-Time 20-29 hours

Job Description

• Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
• Conducts regular audits, as assigned, to ensure guidelines are applied appropriately.
• In states where required, refers all cases that an approval cannot be rendered to the Physician Clinical Reviewer. In States where allowed, will make denial determinations as a specific case warrants.
• Converses with medical office staff in order to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale.
• Provides optimum customer service through professional/accurate communication while maintaining NCQA and health plans required timeframes.
• Documents all communication with medical office staff and/or treating provider.
• Practices and maintains the principles of utilization management by adhering to policies and procedures.
• Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations.

The Experience You’ll Need (Required):

• Current, unrestricted state licensure as a Registered Nurse
• Associate or Bachelors in Nursing (Must be a Registered Nurse)
• 5+ years clinical experience
• Strong interpersonal and communication skills.
• Proficient computer skills; must be able to talk and type simultaneously.

Finishing Touches (Preferred):

• Background in OR, ICU or ER
• Previous UM 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 Health 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. Compensation Range: The minimum salary for this position is $33/hr, plus benefits. Salaries are determined by the skill set required for the position and commensurate with experience and may vary above and below the stated amounts.