Clinical Letter Writer - UM & Specialty Experience is a MUST

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.

Our shared services team offers candidates the opportunity to make a meaningful impact by providing exceptional support to internal and external customers through positive interactions, and timely delivery of high-quality products. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes. Collaboration Opportunities: Works with the physician reviewer to monitor the adverse determination process and ensure notification timeframes are met Works with internal and external staff to ensure that decisions are made, documented, and communicated clearly

The Clinical Letter Writer 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. Reviews adverse determinations against criteria and medical policies 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 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.