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Clinical Reviewer, Nurse – Radiology
EvolentClinical Reviewer, Nurse supporting utilization management team within Evolent to improve patient care outcomes. Collaborating with medical staff while ensuring adherence to clinical criteria and documentation standards.
About the role
Key responsibilities & impact- Functions in a clinical review capacity to evaluate all cases, which do not pass the authorization approval process at first call while promoting a supportive team approach with call center staff.
- Clinical reviewers are supported by Field Medical Directors (MDs) in the utilization management determination process.
- Reviews charts and analyzes clinical record documentation in order to approve services that meet clinical review criteria.
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff.
- Converses with medical office staff to obtain additional pertinent clinical history/information; notifies of approvals and denials, giving clinical rationale, while providing optimum customer service through professional/accurate communication and maintaining NCQA and health plans required timeframes.
- Documents all communication with medical office staff and/or treating provider.
- Practices and maintains the principles of utilization management by adhering to policies and procedures.
- Participates in on-going training programs to ensure quality performance in compliance with applicable standards and regulations, as well as, being audited to ensure guidelines are applied appropriately.
Requirements
What you’ll need- A current RN clinical license, active and in good standing, in your home state- Required
- Associate or Bachelors in Nursing (Must be a Registered Nurse) – Required
- Strong interpersonal and communication skills - Required
- Proficient computer skills; must be able to talk and type simultaneously- Required
- You must be able to work a minimum of 30 hours/week- Required
- Ability to work 3, 4 or 5 days a week- Required
- Start time must be 9am EST or later – Required
- Flexibility to choose length of shift ( ex. 3 (10s) 4 (10s) or 5 (8s) – etc. )
- 5+ years clinical experience- Preferred
Benefits
Comp & perks- health insurance benefits
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
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Hard Skills & Tools
clinical reviewutilization managementchart reviewclinical record analysisquality of care standardsdocumentationcustomer service
Soft Skills
interpersonal skillscommunication skills
Certifications
RN clinical licenseAssociate in NursingBachelor in Nursing