Remote LVN, Utilization Management
- Clinical License LPN, LVN
- State(s) IL
Full Job Description
It’s 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 “Becker’s 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 we’re 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 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.
Who You’ll Be Working With:
The Nurse Reviewer is responsible for performing precertification and prior approvals. Tasks are performed within the LVN/LPN scope of practice, under Medical Director direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. 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.
What You’ll Be Doing:
- Performs utilization review of outpatient procedures and ancillary services.
- Fulfills on call requirements for selected clients as scheduled.
- Determines 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 UM Leadership.
- Appropriately identifies potential cases for Care Management programs
- Collaborates with physicians and other providers to facilitate provision of services throughout the health care continuum.
- Performs accurate data entry.
- Communicates appropriate information to other staff members as necessary/required.
- Participates in continuing education initiatives.
- Collaborates with Claims, Quality Management and Provider Relations Departments as requested.
- Availability on some weekends and holidays may be required
- Performs other duties as assigned.
The Experience You’ll Need (Required):
- State of Illinois practical/vocational nurse license (current and unrestricted)
- High School Diploma or equivalent required
- UM Experience
- 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):
- 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
Currently, Evolent employees work remotely temporarily due to COVID-19. As such, 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 reopening of our office locations.
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.