UR Nurse

Location

Dover, DE | United States

Job description

at Evolent Health in Dover, Delaware, United States

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:

To ensure the appropriate utilization of services and act as an advocate for our members and to ensure the highest quality and cost effective care.

Collaboration Opportunities:

As a UR Nurse of the Utilization Management department you will work closely with other nurses, managers, medical directors, and upper leadership as requested.

What You Will Be Doing:

+ Reviews Provider request for relevant and complete supporting documentation.

+ Requests additional documentation from providers per guidelines

+ Utilizing clinical guidelines approved by the Utilization Management Committee ( UMC ), the URN has the authority to authorize services or procedures. If a request does not meet established clinical guidelines for appropriateness and medical necessity, the request is sent to a physician reviewer. At no time can a URN recommend an adverse determination.

+ Ensures regulatory guidelines are met for timeliness and use of medical review criteria.

+ Verifies accuracy of codes and services and applies them accurately with appropriate documentation.

+ Establishes and maintains professional relationships with Providers and office staff for the purpose of education to establish a smooth operational flow of authorizations and referrals.

+ Educates and supports Utilization Management staff with medication requests, laboratory results and documentation of submissions per approved Evolent policy guidelines.

+ Complies with current URAC standards as they relate to this position.

+ Supports clinical initiatives as identified by the UM department and UMC .

+ Assists Chief Medical Officer ( CMO ), Medical Reviewers and the Clinical Specialist in the submission of developed and approved pathways sent to Information Technology.

+ Assists the Director of UM, Medical Reviewers and Chief Medical Officer to develop report data elements necessary to track and trend utilization practices by provider, practice variation reports, reports to support quality initiatives, and elements to support Evolent dashboard reports.

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

+ Complies with HIPAA requirements and all Evolent policies and procedures.

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

+ Performs other duties as assigned.

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.

Qualifications: Required and Preferred

+ Unrestricted Registered Nurse (RN), LPN or LVN license required for the state of employment.- Required

+ Must be able to work until 5pm PST (8pm EST )- Required

+ Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel. – Preferred

+ Able to work in a fast-paced environment, demonstrate excellent problem solving, critical thinking, and organizational skills. – Preferred

+ Performs multiple tasks efficiently and accurately, have exceptional attention to detail and perform consistent work product validation/QA. – Preferred

+ Bachelor’s degree in Nursing or HealthCare related field – Preferred

+ Excellent customer service skills- Preferred

+ Strong computer skills in MS Excel and Word. – Preferred

+ Ability to easily navigate through website research. – Preferred

+ 2 – 4 years UM experience- Preferred

+ 2 – 3 years in an inpatient or outpatient setting highly- Preferred

+ Specialty certification- Preferred

+ Cardiology experience- Preferred

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. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.

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 [email protected] for further assistance.

The expected base salary/wage range for this position is $39/hr.. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive 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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