Registered Nurse

Company: Evolent Health
Location: Louisville
Posted on: September 15, 2020

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: Evolentachieveda 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.**What You'll Be Doing:**The Nurse Reviewer - Clinical Letter Writer (RN) is responsible for reviewing adverse determination decisions against criteria and policy, escalating questions to the physician reviewer, and creating letters that meet regulatory and Plain Language requirements. This position requires a person who can synthesize various clinical and administrative requirements, communicate well with the team and clients, and write clearly.**Responsibilities**+ Reviews adverse determinations against criteria and medical policies+ Assist with IP reviews+ Works with the physician reviewer to monitor the adverse determination process and ensure notification time frames are met+ Creates adverse determination notifications that meet all accreditation, State, and Federal criteria+ Uses Plain Language and good written skills to clearly communicate adverse decisions to both members and providers+ Works with internal and external staff to ensure that decisions are made, documented and communicated clearly+ Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director.+ Appropriately identifies potential cases for Care Management programs+ 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.+ Performs other duties as assigned.**The Experience You'll Need (Required):**+ Licensed registered nurse (current and unrestricted)+ Minimum of three years of direct clinical patient care+ Minimum of one year of experience with medical management activities in a managed care environment+ Excellent written skills+ Knowledge of managed care principles, HMO and Risk Contracting arrangements.+ UM review experience using clinical decision-making criteria sets, i.e InterQual or Milliman review criteria+ Strong interpersonal, oral and written communication skills.+ Possess basic computer skills**Technical requirements:**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 re-opening 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.**

Keywords: Evolent Health, Louisville , Registered Nurse, Healthcare , Louisville, Kentucky