Clinical Reviewer, Nurse – Cardiology
Evolent
full-time
Posted on:
Location Type: Remote
Location: Remote • 🇺🇸 United States
Visit company websiteJob Level
SeniorLead
About the role
- Functions in a clinical review capacity to evaluate all cases which do not pass the authorization approval process at first call
- Routinely interact with leadership and management staff, other CR’s, providers, office staff and Field Medical Directors (FMDs)
- Reviews charts and analyzes clinical record documentation 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
- Provides 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 and may be audited to ensure guidelines are applied appropriately
Requirements
- Current, unrestricted state licensure as a Registered Nurse- Required
- Associate or Bachelors in Nursing (Must be a Registered Nurse) – Required
- You must be able to work a minimum of 30 hours/week- Required
- Must be able to work between the hours of Monday-Friday, 8am-11pm Central Standard Time- Required
- Strong interpersonal and communication skills - Required
- Proficient computer skills; must be able to talk and type simultaneously- Required
- Offering 30+ hours a week - Preferred
- Offering hours Monday-Friday 230pm-11pm Central Standard Time - Preferred
- 5+ years clinical experience- Preferred
- Submission of a government issued photo ID for identity verification during interviews
- Final interviews may require onsite attendance
- All candidates must complete a comprehensive background check, in-person I-9 verification, and may be subject to drug screening prior to employment
- The use of artificial intelligence tools during interviews is prohibited and monitored
Benefits
- Work at Home
- better work- life balance on a team that values collaboration and continuous learning
- Meaningful way to make a difference in patients’ lives, in a non-clinical environment
- Support for career and growth
- Company recognition and awards (Evolent Health International certified “Great Places to Work”; Best Company for Women to Advance; HRC Foundation CEI perfect score)
- Inclusive workplace and community involvement (employees give back to communities)
Applicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard skills
clinical reviewchart reviewclinical record documentationutilization managementquality of care standardscustomer servicecommunicationcomputer skills
Soft skills
interpersonal skillscommunication skills
Certifications
Registered Nursestate licensure