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Clinical Reviewer, Nurse Practitioner/Physician Assistant – Oncology
EvolentClinical Reviewer for Oncology at Evolent, managing administrative and clinical utilization management. Requires advanced nursing degree and experience in Oncology.
About the role
Key responsibilities & impact- Responsible for support and assistance for all Oncology administrative and clinical utilization management and quality improvement functions under the auspices of the office of the Chief Medical Officer.
- Conducts initial clinical review of incoming cases, rendering authorization approval based on established clinical criteria or escalating to a Field Medical Director if authorization cannot be approved during initial review.
- Responsible for acting as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
- Responsible for clinical conversations with providers and their office staff regarding medical necessity decisions.
- Responsible for maintaining and operating the Guideline Directed Treatment plans including communicating with offices regarding treatment recommendation.
- Responsible for communicating need for additional clinical information to ordering providers.
- Responsibility for prepping cases which cannot be approved and which the provider will not modify or withdraw for P2P discussions with one of the Oncologists.
- Responsible for coordinating with UM staff to ensure timely and accurate communication of clinical decisions.
- Responsible for completion of UM projects and participation in site visit reviews.
- Respect and maintain HIPAA confidentiality guidelines.
- Responsible for maintaining availability to clinical and non-clinical administrative staff during performance of initial and second level screening.
- Acts as an interdepartmental liaison between all offices, departments, and committees.
- Serve as subject matter expert and participate in meetings as assigned with practices and/or payers.
- Will work with the Director of Clinical Operations to ensure client satisfaction.
- Perform all peer clinical review activities while located in a state or territory of the United States.
- Acts with honor and integrity, serving as a role model for the company.
- Performs other duties as assigned.
Requirements
What you’ll need- Master of Science in Nursing or Doctor of Nursing Practice (DNP) degree from a recognized degree program OR a master’s degree from a program accredited the ARC-PA.
- Minimum of three (3) to five (5) years’ experience in the practice of Oncology (required);
- Knowledge of regulatory requirements with at least two years of experience in a regulatory role (preferred).
- Current, unrestricted state PA or RN/NP license in medicine or required specialty
- Licensed in Home State
- If a PA, obtaining a passing score on a national certifying exam
- Obtaining and maintaining required licenses, per business need
- Strong clinical, management, communication, and organizational skills.
- Demonstrated leadership skills
- Analytic skills
- Energetic and curious with a passion for quality and value in health care
- Required to pass skills proficiency test.
Benefits
Comp & perks- health insurance benefits
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills & Tools
clinical reviewauthorization approvalutilization managementtreatment planspeer clinical reviewregulatory requirementsOncology practiceanalytical skillsskills proficiency test
Soft Skills
communication skillsorganizational skillsleadership skillsinterdepartmental liaisonrole modelenergeticcuriouspassion for qualityintegrity
Certifications
Master of Science in NursingDoctor of Nursing PracticePA or RN/NP licensenational certifying exam