Healthcare & Clinical
Utilization Review Nurse
Remote, United States
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.

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.

Who You'll Be Working With: 
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.

What You'll Be Doing:

  • 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.

The Experience You'll Need (required):
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.
  • Bachelor’s degree in Nursing or HealthCare related field preferred. Unrestricted Registered Nurse (RN), LPN or LVN license required for the state of employment.
  • Excellent customer service skills
  • Strong computer skills in MS Excel and Word.
  • Ability to easily navigate through website research.
Finishing Touches (preferred):
  • 2 - 4 years UM experience preferred.
  • 2 - 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.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

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