Job Openings Nurse (PhRN) - Utilization Management

About the job Nurse (PhRN) - Utilization Management

Its 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 Beckers 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 Glassdoors 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.

Working Hours: 9:00am-6:00pm Central

What Yo'ull Be Doing:

  • Performs precertification, prior approvals, and monitoring activities for mental health and substance abuse problems
  • 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.
  • Determines medical necessity and appropriateness of services using clinical review criteria based information given by providers.
  • Accurately documents all review determinations and contacts providers and members according to established timeframes.
  • Identifies and refers cases that do not meet established clinical criteria to the Medical Director.
  • Identifies and refers quality issues to the Director of Medical Management or Medical Director.
  • Identifies potential cases for Care Management programs.
  • Performs accurate data entry in order to meet quality goals.
  • Communicates information to other staff members as necessary/required.
  • Participates in continuing education initiatives.
  • Collaborates with Claims, Quality Management and Provider Relations Departments as requested.
  • Other duties as assigned.

The Experience You Need (Required):

  • Actively independently licensed in (LCSW, LCPC, RN)
  • Masters degree in Behavioral Health or RN
  • Minimum of three years of direct clinical patient care
  • Minimum of one year of experience with medical management activities in a managed care environment

Finishing Touches (Preferred):

  • We are looking for team members who possess enthusiasm, a strong work ethic, integrity, who are kind and empathetic, have a sense of humor, and who enjoy working in a collaborative, team-oriented system.
  • 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