[Hiring] Clinical Reviewer, Nurse @Evolent

Role Description

The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed within the RN scope of practice, under the Medical Director's direction, using independent nursing judgment and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum and working with the health care delivery team to maintain high-quality, cost-effective care.

• Perform pre-certification utilization reviews of Oncology treatment requests (chemotherapy).
• Determine medical necessity and appropriateness of services using clinical review criteria.
• Accurately document all review rationales and determinations.
• Appropriately identify and refer cases that do not meet established clinical criteria to the Medical Director.
• Appropriately identify and refer quality issues to UM Leadership.
• Collaborate with physicians and other providers to facilitate the provision of services throughout the health care continuum.
• Perform accurate data entry.
• Communicate appropriate information to other staff members as necessary/required.
• Participate in continuing education initiatives.
• Availability on some weekends and holidays may be required.
• Perform other duties as assigned.

Qualifications

• Registered Nurse with a current, unrestricted license in your state of residence.
• Associates or Bachelor's Degree in Nursing.
• Minimum of three years of direct clinical patient care (acute, inpatient, or critical care setting); strongly prefer direct Oncology experience.
• Strong computer skills, including MS Office Suite.
• Strong interpersonal, oral, and written communication skills.
• Availability for 9 AM-6 PM Monday through Friday shift with weekend & holiday rotation.

Requirements

• Experience with clinical decision-making criteria sets (NCCH, Clinical Pharmacology).
• UM/UR experience.
• Clinical experience in Oncology.
• ONS/ONCC Chemotherapy Immunotherapy Certificate or OCN certification.
• Remote work experience.

Benefits

• Comprehensive benefits (including health insurance benefits) to qualifying employees.

Company Description

Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the fragmented health care system and ensure people receive 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 the autonomy they need to get things done. We believe people do their best work when they're supported to live their best lives and 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.