Utilization Management Nurse

Evolent Health - Remote3.6

Full-time
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—70.3% in year-over-year revenue growth in 2017. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016 and 2017, and one of the “50 Great Places to Work” in 2017 by Washingtonian, and our CEO was number one on Glassdoor’s 2015 Highest-Rated CEOs for Small and Medium Companies. 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.

New Century Health merged with Evolent Health in 2018 and continues to lead transformative change in specialty care management as an Evolent company. Within the Evolent ecosystem of provider-centric solutions for value-based care, our New Century Health team focuses on cost and quality improvement for oncology and cardiology specialty care. With more than 15 years of proven results, New Century Health generates insights and drives cutting edge innovation through its clinical capabilities and deep understanding of health care informatics, physician management and health care technology systems development. Together, Evolent and New Century Health are harnessing the power of our combined organizations to improve the health of the nation. Join the New Century Health team and put your passion to work for transforming the U.S. health care landscape for patients, providers and payers.

SUMMARY: The Utilization Review Nurse (URN) is involved with every aspect of the utilization process to include: case receipt and entry, Chemotherapy/Cardiology Treatment Regiment authorization requests, referrals, approvals and case preparation for medical review, claims review, request and review medical records. This position plays a pivotal role in the clinical management of New Century Health’s Utilization Management programs.

ESSENTIAL DUTIES AND RESPONSIBILITIES: include the following. Other duties may be assigned.

Reviews Provider request for relevant and complete supporting documentation.
Requests additional documentation per New Century Health (NCH) policy.
Utilizing clinical guidelines approved by NCH Utilization Management Committee (UMC), the URN has the authority to authorize services or procedures. If a request does not meet established clinical guidelines for appropriateness and medical necessity, the request is sent to a physician reviewer. At no time can a URN recommend an adverse determination.
Ensures regulatory guidelines are met for timeliness and use of medical review criteria.
Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
Establishes and maintains professional relationships with Providers and office staff for the purpose of education to establish a smooth operational flow of authorizations and referrals.
Educates and supports UM staff with medication requests, laboratory results and documentation of submissions per approved NCH policy guidelines.
Complies with current URAC standards as they relate to this position.
Supports clinical initiatives as identified by the UM department and UMC.
Assists Chief Medical Officer (CMO), Medical Reviewers and the Clinical Specialist in the submission of developed and approved pathways sent to Information Technology.
Assists the Director of UM, Medical Reviewers and CMO to develop report data elements necessary to track and trend utilization practices by provider, practice variation reports, reports to support quality initiatives, and elements to support NCH dashboard reports.
Acts with honor and integrity, serving as a role model for the company.
Complies with HIPAA requirements and all NCH policies and procedures.
Acts as an interdepartmental liaison between all NCH offices, departments, and committees.
Performs other duties as assigned.

QUALIFICATION REQUIREMENTS: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel.
Able to work in a fast-paced environment, demonstrate excellent problem solving, critical thinking, and organizational skills.
Performs multiple tasks efficiently and accurately, have exceptional attention to detail and perform consistent work product validation/QA.
Self-motivated, self-directed, team oriented, and responsible, with a positive attitude and a proactive style. Possesses the ability to operate in a highly variable work environment.
Presents a courteous and competent demeanor to our clients and teammates.

EDUCATION and/or EXPERIENCE:
Bachelor’s degree in Nursing or HealthCare related field preferred. Unrestricted Registered Nurse (RN), LPN or LVN license required for the state of employment. Two (2) to four (4) years UM experience preferred. Two (2) to three (3) years in an inpatient or outpatient setting highly preferred. Specialty certification preferred. Ability to review medical records and identify codes for claims processing preferred. Oncology and/or cardiology experience highly preferred.

OTHER SKILLS and ABILITIES:
Must have excellent customer service skills and strong computer skills in MS Excel and Word. Must have the ability to easily navigate through website research.

PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms; and talk or hear. The employee frequently is required to sit. The employee is occasionally required to stand and walk.

The employee must occasionally lift and/or move up to 25 pounds. Specific vision abilities required by this job include close vision.

WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.