RN, Care Advisor

Job Description

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 power that brings us to work each day. We believe in embracing new ideas, testing 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. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts: Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign's Corporate Equality Index; was named on the Best Companies for Women to Advance List 2020 by Parity.org; and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. 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.

What You’ll Be Doing:

The RN Care Advisor, Utilization Management (UM) is accountable 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.

Responsibilities

· Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services.

· Determines medical necessity and appropriateness of services using clinical review criteria.

· Accurately documents data and all review determinations, and contacts providers and members according to established time frames.

· Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.

· Appropriately identifies and refers quality issues to the Director and Senior Director of Utilization Management.

· Appropriately identifies potential cases for Care Management programs

· Partners with physicians and other providers to facilitate provision of services throughout the health care continuum.

· Participates in continuing education initiatives.

· Works with with Claims, Quality Management and Provider Relations Departments as requested.

· Potential need for availability on some weekends and holidays.

· Performs other duties as assigned.

The Experience You’ll Need:

· Licensed registered nurse (current and unrestricted)

· Associate or Bachelor Degree (preferred) in Nursing.

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

· Knowledge of managed care, community healthcare resources, 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

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such 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 Health 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.