Clinical Reviewer Jobs in Wisconsin (NOW HIRING)

Work at Home

Full time

JR-916302

Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You'll Be Doing:

The Nurse Practitioner/Physician Assistant (ARNP/NP/PA) Oncology is responsible for support and assistance for all Oncology administrative and clinical utilization management and quality improvement functions under the auspices of the office of the Chief Medical Officer.

ESSENTIAL DUTIES AND RESPONSIBILITIES :

• Conducts initial clinical review of incoming cases, rendering authorization approval based on established clinical criteria or escalating to a Field Medical Director if authorization cannot be approved during initial review.

• Responsible for acting as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.

• Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.

• Responsible for maintaining and operating the Guideline Directed Treatment plans including communicating with offices regarding treatment recommendation.

• Responsible for communicating need for additional clinical information to ordering providers.

• Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the Oncologists.

• Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.

• Responsible for completion of UM projects and participation in site visit reviews.

• Respect and maintain HIPAA confidentiality guidelines.

• Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening

• Acts as an interdepartmental liaison between all offices, departments, and committees.

• Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.

• Will work with the Director of Clinical Operations to ensure client satisfaction.

• Perform all peer clinical review activities while located in a state or territory of the United States.

• Acts with honor and integrity, serving as a role model for the company.

• 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.

EDUCATION and/or EXPERIENCE:

• Master of Science in Nursing or Doctor of Nursing Practice (DNP) degree from a recognized degree program OR a master's degree from a program accredited the ARC-PA.

• Minimum of three (3) to five (5) years' experience in the practice of Oncology (required);

• Knowledge of regulatory requirements with at least two years of experience in a regulatory role (preferred).

LICENSE/CERTIFICATION:

• Current, unrestricted state PA or RN/NP license in medicine or required specialty

• Licensed in Home State

• If a PA, obtaining a passing score on a national certifying exam

• Obtaining and maintaining required licenses, per business need

• A clinical license, active and in good standing, in your home state is required

OTHER SKILLS and ABILITIES:

• Strong clinical, management, communication, and organizational skills.

• Demonstrated leadership skills

• Analytic skills

• Energetic and curious with a passion for quality and value in health care

• Required to pass skills proficiency test

To ensure a secure hiring process we have implemented several identity verification steps, including submission of a government issued photo ID. We conduct identity verification during interviews, and final interviews may require onsite attendance. All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment. The use of artificial intelligence tools during interviews is prohibited and monitored. Misrepresentation will result in immediate disqualification from consideration.

Technical Requirements:

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.

Evolent 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. If you need reasonable accommodation to access the information provided on this website, please contact recruitingteam@evolent.com for further assistance.

The expected base salary/wage range for this position is $68-$73/hr. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.

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