About the job UM Nurse
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 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 Beckers 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 were 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 youre looking for a place where your work can be personally and professionally rewarding, dont just join a company with a mission. Join a mission with a company behind it.
Utilization Management (UM) Nurse
The UM Nurse is responsible for performing precertification, prior approvals, concurrent and retrospective reviews, and coordination of discharge planning. 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.
Roles & Responsibilities
- Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services.
- Concludes medical necessity and appropriateness of services using clinical review criteria.
- Accurately documents all review determinations and contacts providers and members according to established timeframes.
- Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.
- Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director.
- Appropriately identifies potential cases for Care Management programs
- Partners with physicians and other providers to facilitate provision of services throughout the health care continuum.
- Performs accurate data entry.
- Conveys appropriate information to other staff members as necessary/required
- Participates in continuing education initiatives.
- Works with Claims, Quality Management and Provider Relations Departments as requested.
- Performs other duties as assigned.
- An active and unrestricted Nursing license in the Philippines and mainland US
- Minimum of one (1) year experience in Utilization Management/Review
- Strong clinical knowledge, direct clinical patient care experience for at least a year is preferred
- Experience in managed care and health insurance is an advantage
- Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
- Strong interactive, oral and written communication skills.
- Proficiency with PC-based software programs including Word, Excel and Outlook
- Strong critical thinking, analytical, research and organizational skills
- Ability to work remotely and independently
- Basic knowledge and understanding of medical coding and claims processing
- Hours of Training and Operations: US Business Hours
- Trainees will be required to maintain regular attendance and successfully complete the required training and demonstrate proficiency of the material at the end of training.
Compensation & Benefits
- Earn as much as 80,000 up to 90,000 per month;
- HMO coverage includes you and a dependent.
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.