Nurse Reviewer (RN) Clinical Letter Writer
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? Absolutely56.7% in year-over-year revenue growth in 2016. 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.
The Nurse Reviewer Clinical Letter Writer (RN) is responsible for reviewing adverse determination decisions against criteria and policy, escalating questions to the physician reviewer, and creating letters that meet regulatory and Plain Language requirements. This position requires a person who can synthesize various clinical and administrative requirements, communicate well with the team and clients, and write clearly.
Reviews adverse determinations against criteria and medical policies
Works with the physician reviewer to monitor the adverse determination process and ensure notification timeframes are met
Creates adverse determination notifications that meet all accreditation, State, and Federal criteria
Uses Plain Language and good written skills to clearly communicate adverse decisions to both members and providers
Works with internal and external staff to ensure that decisions are made, documented and communicated clearly
Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director.
Appropriately identifies potential cases for Care Management programs
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.
Licensed registered nurse (current and unrestricted)
Minimum of three years of direct clinical patient care
Minimum of one year of experience with medical management activities in a managed care environment
Excellent written skills
Knowledge of managed care principles, HMO and Risk Contracting arrangements.
Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
Strong interpersonal, oral and written communication skills.
Possess basic computer skills
Evolent Health is an Equal Opportunity/Affirmative Action Employer
Evolent Health, Inc.