Clinical Reviewer, Nurse

Evolent • San Juan, PR • 2d 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!

Hospital & Medical

Datavant is a data platform company and the world's leader in health data exchange. Our vision is that every healthcare decision is powered by the right data, at the right time, in the right format. Our platform is power...

1w ago

Go to Apply

Abarca Health, LLC. • San Juan, PR • 1w ago

Hospital & Medical

What you'll do In a few words... Abarca is igniting a revolution in healthcare. We built our company on the belief that with smarter technology we are redefining pharmacy benefits, but this is just the beginning... The P...

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.