Clinical Reviewer, Nurse (Medical Oncology)

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.

Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the fragmented health care system and ensure people receive 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 the autonomy they need to get things done. We believe people do their best work when they're supported to live their best lives and 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.

The Clinical Review Nurse is responsible for performing precertification and prior approvals. Tasks are performed within the RN/LVN/LPN scope of practice, under the Medical Director's direction, using independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. The Clinical Review Nurse serves as a member advocate, expediting care across the continuum and working with the health care delivery team to maintain high-quality, cost-effective care. Perform pre-certification utilization reviews of Oncology treatment requests (chemotherapy) Determines medical necessity and appropriateness of services using clinical review criteria. Accurately documents all review rationales and determinations. Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director. Appropriately identifies and refers quality issues to UM Leadership. Collaborates with physicians and other providers to facilitate the provision of services throughout the health care continuum. Performs accurate data entry. Communicates appropriate information to other staff members as necessary/required. Participates in continuing education initiatives. Availability on some weekends and holidays may be required. Performs other duties as assigned.