Job Location : Harrisburg,PA, USA
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: As a Clinical Reviewer, Nurse, you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes. Collaboration Opportunities: As a Clinical Reviewer, Nurse, you will routinely interact with leadership and management staff, other CRs (Clinical Reviewers), providers, office staff and Field Medical Directors. What You Will Be Doing: 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. Clinical Reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process. 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. Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale, while providing optimum customer service through professional/accurate communication and 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, as well as, being audited to ensure guidelines are applied appropriately. Qualifications: Current, unrestricted state licensure as a Registered Nurse Associate or Bachelors in Nursing (Must be a Registered Nurse) Strong interpersonal and communication skills Need Cardiac Nursing Experience Proficient computer skills; must be able to talk and type simultaneously 5 years clinical experience is preferred Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an excluded person by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare. No history of disciplinary or legal action by a state medical board 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 recruitingevolent.com for further assistance. The expected base salary/wage range for this position is $. 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 For more insights about Evolent Health, click on Life At Evolent ( to learn more