Appeals Nurse

Your Future Evolves Here Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones. Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business. Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing: The Evolent Appeals Nurse team offers candidates the opportunity to make a meaningful impact as part of a highly trained dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and client policies and procedures while complying with timeliness guidelines. Our clinical nurse reviewer team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the clients and members we serve. Collaboration Opportunities: The Appeals Nurses provide appeal reviews for dedicated clients. They interact with coordinators who set up the appeal, physicians and other clinicians who review the appeal, the claims department to review provider post-service claims for medical necessity, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats and monthly communication on team metrics and accomplishments.

Communicates with medical office personnel to obtain pertinent clinical history and information. Documents and summarizes clinical or administrative rationale for all approvals and denials to all parties involved in the case. Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews. Participates in on-going training programs to ensure quality performance follows applicable standards and regulations. Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures. Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes. Documents communications with medical office staff and/or MD provider as required. Refers cases to appropriate internal reviewers according to the business needs of the particular health plan. Research requests for post-determination review and categorizes each for processing based on the applicable health plan policies and procedures. Reviews and coordinates documentation; interprets data obtained from clinical records and ensures appropriate clinical criteria and policies are aligned with regulatory and accreditation requirements for members and providers. Tracks all post-determination cases to completion to ensure compliance. Trains new employees on the appeals and de-certification process as needed. Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals.