Utilization Review RN/LVN

Company: Evolent Health
Location: Santa Fe
Posted on: May 14, 2022

Job Description:

**It's Time For A Change---****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 in everything from scrubs to jeans.Are we growing? Absolutely - about 40% in year-over-year revenue growth in 2018. Are we recognized? Definitely. We have been named one of "Becker's 150 Great Places to Work in Healthcare" in 2016, 2017, 2018 and 2019, and one of the "50 Great Places to Work" in 2017 by Washingtonian. 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:**What You'll Be Doing:The Nurse Reviewer is accountable for performing precertification, prior approvals, concurrent and retrospective reviews, and coordination of discharge planning. Tasks are performed within the RN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum, working in concert with the health care delivery team to maintain high quality and cost effective care delivery.Essential FunctionsAll Levels:Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services.Determines medical necessity and appropriateness of services using clinical review criteria.Accurately documents all review determinations and contacts providers and members according to established timeframes.Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director.Appropriately identifies potential cases for Care Management programsCollaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.Performs accurate data entry.Communicates appropriate information to other staff members as necessary/required.Participates in continuing education initiatives.Collaborates with Claims, Quality Management and Provider Relations Departments as requested.Performs other duties as assigned.Level 2 Additional Functions:Functions as the key contact and utilization management expert for a client, business line, or product.Duties may include clinical and operational meeting attendance, day-to-day oversight of work streams, and reporting analysis and action developmentThe Experience You'll Need (Required):Licensed registered nurse (current and unrestricted)Associate or Bachelor Degree in Nursing required; Bachelor Degree preferredPreferred Experience We Look For:Minimum of one year with medical management activities in a managed care environment, Medicaid managed care preferredKnowledge of managed care principles, HMO and Risk Contracting arrangements.Knowledge of health care resources within the communityClinical decision-making criteria sets (i.e. Milliman, InterQual)Strong interpersonal, oral and written communication skills.Possess basic computer skills**Technical requirements:**Currently, Evolent employees work remotely temporarily due to COVID-19. As such, 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 Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.**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.**Compensation Range: The typical range of employees within the compensation grade of this position is . Salaries are determined by the skill set required for the position and commensurate with experience and may vary above and below the stated amounts.

Keywords: Evolent Health, Santa Fe , Utilization Review RN/LVN, Healthcare , Santa Fe, New Mexico