- The Nurse Reviewer is responsible 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 self-directed 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.
- Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services.
- Concludes 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 programs
- Partners with physicians and other providers to facilitate provision of services throughout the health care continuum.
- Performs accurate data entry.
- Conveys appropriate information to other staff members as necessary/required
- Participates in continuing education initiatives.
- Works with Claims, Quality Management and Provider Relations Departments as requested.
- Performs other duties as assigned.
- Licensed registered nurse (current and unrestricted)- required
- Associate or Bachelor Degree in Nursing required; Bachelor Degree -preferred
- Minimum of three years of direct clinical patient care- preferred
- Minimum of one year of experience with medical management activities in a managed care environment, Medicaid managed care -preferred
- Knowledge of managed care standards, HMO and Risk Contracting arrangements. - preferred
- Knowledge of health care resources within the community - preferred
- Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual) - preferred
- Strong interactive, oral and written communication skills. - required
- Possess basic computer skills - required
- Ability to understand and apply highly technical specifications to healthcare datasets - Required.
- Strong verbal & written skills and excellent communication & presentation skills. Comfortable presenting complex analyses - Required.
- Experience with healthcare data sources (claims, billing data, eligibility, etc.) & detailed knowledge of CPT/HCPCS/ICD9/ICD10 – Preferred
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RN Care Advisor, UM - Oklahoma City, United States - Evolent Health
Description
Your Future Evolves Here
Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get 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 autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they 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.
What You'll Be Doing:
To provide honest, innovative, and applicable intelligence around risk adjustment to help our clients thrive and promote equitable reimbursement.
Collaboration Opportunities:
What You Will Be Doing:
Qualifications Required and Preferred:
Technical Requirements:
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 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.If you need reasonable accommodation to access the information provided on this website, please further assistance.
The expected base salary/wage range for this position is $85,000. 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 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.
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
For more insights about Evolent Health, click on Life At Evolent ) to learn more
