[Hiring] Clinical Reviewer, Nurse (Medical Oncology) @Evolent

Role Description

The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed within the RN/LVN/LPN scope of practice, under the Medical Director's direction, using independent nursing judgement 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 in concert with the health care delivery team to maintain high-quality, cost-effective care delivery.

• Perform pre-certification utilization reviews of Oncology treatment requests
• Determine medical necessity and appropriateness of services using clinical review criteria
• Accurately document all review rationales and determinations
• Identify and refer cases that do not meet established clinical criteria to the Medical Director
• 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 or Licensed Practical/Vocational Nurse with a current, unrestricted license
• High School Diploma or equivalent required
• 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 weekend holiday rotation

Requirements

• Experience with clinical decision-making criteria sets (i.e., Milliman, InterQual)
• Minimum of one year of experience with medical management activities in a managed care environment
• UM/UR experience
• Clinical experience in Oncology, ICU, ED, or other critical care environment
• Remote work experience

Technical Requirements

• High speed internet over 10 Mbps
• Ability to plug in directly to the home internet router for all call center employees

Benefits

The expected base salary/wage range for this position is $32-$37 /hr. 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.