Utilization Review Nurse

Evolent Health, Inc. Louisville , KY 40202

Posted 2 months ago

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? 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.

What You'll Be Doing:

The Nurse, UM 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 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 Functions

All 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 programs

  • Collaborates 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 development

The Experience You'll Need (Required):

  • Licensed registered nurse (current and unrestricted)

  • Associate or Bachelor Degree in Nursing required; Bachelor Degree preferred

  • Minimum of three years of direct clinical patient care

  • Minimum of one year of experience with medical management activities in a managed care environment, Medicaid managed care preferred

  • Knowledge of managed care principles, HMO and Risk Contracting arrangements.

  • Knowledge of health care resources within the community

  • 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


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Utilization Review Nurse

Evolent Health, Inc.