Utilization Review Manager Jobs in Rhode Island (NOW HIRING)

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:

As a Field Medical Director, MSK Surgery you will be a key member of the utilization management team. We can offer you a meaningful way to make a difference in patients’ lives, in a non-clinical environment. You can enjoy better work- life balance on a team that values collaboration and continuous learning while providing better health outcomes.

Collaboration Opportunities:

• Routinely interacts with leadership and management staff, other Physicians, and staff whenever a physician`s input is needed or required.

What You Will Be Doing:

• Serve as the Physician match reviewer in Hip/Knee/Shoulder Surgery cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.

• Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request and provides clinical rationale for standard and expedited appeals.

• Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.

• Aids and acts as a resource to Initial Clinical Reviewers.

• Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.

• May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.

• Participates in on-going training per inter-rater reliability process.

Qualifications:

• MD/DO/MBBS

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

• Minimum of five (5) years’ experience in the practice of Medicine, post residency and Active Clinical practice within the last 2 years is highly preferred

• Current, unrestricted clinical license in medicine or required specialty

• Obtaining and maintaining medical licenses in the state you reside, as well as, any license required per business needs

• Active Board Certification in Orthopedic Surgery

• Strong clinical, management, communication, and organizational skills

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

• Computer Proficiency

• Not under current exclusion or sanction by any state or federal health care program, including Medicare or Medicaid, and is not identified as an “excluded person” by the Office of Inspector General of the Department of Health and Human Services or the General Service Administration (GSA), or reprimanded or sanctioned by Medicare.

• No history of a major disciplinary or legal action by a state medical board

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 $135-$150/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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