Clinical Reviewer, Nurse

Evolent • Concord, NH • 12h ago

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. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference working in everything from scrubs to jeans.

Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as "Great Places to Work" in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation's Corporate Equality Index (CEI). This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.

We recognize employees that live our values, give back to our communities each year, and are champions for bringing our 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.

What You'll 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 CR's (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)

Experience as an RN in a Pain MNGT setting is preferred.

Strong interpersonal and communication skills

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

Mandatory Requirements:

Employees must have a high-speed broadband internet connection with a minimum speed of 50 Mbps and the ability to set up a wired connection to their home network to ensure effective remote work. These requirements may be updated as needed by the business.

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 .

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!

Evolent

Go to Apply

Share this job

Similar Jobs

Medicaid State Technology Lead

Humana • Concord, NH • 5h ago

Hospital & Medical

Become a part of our caring community and help us put health first The State Technology Lead understands departmental and IT organizational strategy and operating objectives, including their linkages to related areas. Th...

5h ago

Go to Apply

Environmental/Health/Safety, Facilities, & Maintenance Co-op - US - Fall 2026

GE Aerospace • Hooksett, NH • 1d ago

Hospital & Medical

Job Description Summary Are you ready to see your future take flight? At GE Aerospace, we believe the world works better when it flies. We are a world-leading provider of jet engines, components, and integrated systems f...

1d ago

Go to Apply

Licensed Nursing Assistant - LNA

Genesis Healthcare • Concord, NH • 1d ago

Hospital & Medical

Overview At Genesis Healthcare, we are dedicated to improving the lives we touch through the delivery of high-quality care and exceptional service. As a leading provider in the long-term care industry, we believe in fost...

1d ago

Go to Apply

Manager, Medical Economics

CVS Health • Concord, NH • 1d ago

Hospital & Medical

At CVS Health, we're building a world of health around every consumer and surrounding ourselves with dedicated colleagues who are passionate about transforming health care. As the nation's leading health solutions compan...

1d ago

Go to Apply

Connect Care Medical Assistant

Intermountain Health • Concord, NH • 1d ago

Hospital & Medical

Job Description: A Medical Assistant II performs routine clerical and clinical tasks within the clinic, assisting Physicians and other licensed providers to provide quality patient care efficiently and cost effectively....

1d ago

Go to Apply

NLP & LLM Data Scientist - Healthcare & Life Sciences

Norstella • Concord, NH • 1d ago

Hospital & Medical

NLP & LLM Data Scientist - Healthcare & Life Sciences Company: Norstella Location: Remote, United States Date Posted: Aug 17, 2025 Employment Type: Full Time Job ID: R-1387 Description About Norstella At Norstell...

1d ago

Go to Apply

Care Manager, Telephonic Nurse

CenterWell • Concord, NH • 2d ago

Hospital & Medical

Become a part of our caring community and help us put health first This full time 40 hours a week position will be scheduled Monday-Friday, 10am-6:30pm EST. This position also requires a weekend rotation every third week...

2d ago

Go to Apply

Physical Therapist- Home Health

Elara Caring • Manchester, NH • 5d ago

Hospital & Medical

At Elara Caring, we have a unique opportunity to play a huge role in the growth of an entire home care industry. Here, each employee has the chance to make a real difference by carrying out our mission every day. Join ou...

5d ago

Go to Apply

Acute Inpatient Registered Nurse - RN

Fresenius Medical Care North America • Manchester, NH • 6d ago

Hospital & Medical

This position will cover Elliot Hospital, Concord Hospital, and Catholic Medical Center. Hospitals are close to each other. You will be working with a skilled and dynamic team as well as with Nephrologist who are pro-Nur...

6d ago

Go to Apply

Registered Nurse-Patient Aligned Care Team (PACT)

Veterans Affairs, Veterans Health Administration • Manchester, NH • 1w ago

Hospital & Medical

Summary This position is eligible for the Education Debt Reduction Program (EDRP), a student loan payment reimbursement program. You must meet specific eligibility requirements per VHA policy and submit your EDRP applica...

1w ago

Go to Apply

Subscribe to get new jobs sent directly to you
(no charge, cancel anytime)

This site is protected by reCAPTCHA and the Google Privacy Policy and Terms of Service apply.