Clinical Reviewer, Nurse – Medical Oncology

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🔥 22 minutes ago

🇺🇸 United States – Remote

💵 $34 - $38 / hour

⏰ Full Time

🟡 Mid-level

🟠 Senior

🔍🏥 Medical Reviewer

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Evolent

WebsiteLinkedInAll Job Openings

1001 - 5000 employees

⚕️ Healthcare Insurance

☁️ SaaS

Healthcare Insurance • Healthcare • SaaS

Evolent is a healthcare company focused on improving care outcomes through its comprehensive management solutions across multiple medical specialties. They aim to enhance the patient care journey by offering coordinated services in areas like oncology, cardiology, musculoskeletal disorders, and primary care, while ensuring high-quality treatment pathways and cost management. Evolent believes every person deserves quality care, striving to align treatment guidelines and innovative approaches to meet patient needs effectively.

📋 Description

• The Clinical Review Nurse is responsible for performing precertification and prior approvals. • Tasks are performed within the RN scope of practice, under the Medical Director's direction. • Uses independent nursing judgement and decision-making, physician-developed medical policies, and clinical decision-making criteria sets. • Serves as a member advocate, expediting care across the continuum. • Works with the health care delivery team to maintain high-quality, cost-effective care. • Performs pre-certification utilization reviews of Oncology treatment requests (chemotherapy). • Accurately determines medical necessity and appropriateness of services using clinical review criteria. • Documents all review rationales and determinations accurately. • Identifies and refers cases that do not meet established clinical criteria to the Medical Director. • Identifies and refers quality issues to UM Leadership appropriately. • 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.

🎯 Requirements

• Registered Nurse with a current, unrestricted license in your state of residence • Associates or Bachelor's Degree in Nursing • Minimum of three years of direct clinical patient care (acute, inpatient, or critical care setting); strongly prefer direct Oncology experience. • Strong computer skills, including MS Office Suite • Strong interpersonal, oral, and written communication skills. • Availability for 9 AM-6 PM Monday through Friday shift with weekend & holiday rotation. • Experience with clinical decision-making criteria sets (NCCH, Clinical Pharmacology) preferred. • UM/UR experience preferred. • Clinical experience in Oncology preferred. • ONS/ONCC Chemotherapy Immunotherapy Certificate or OCN certification preferred. • Remote work experience preferred.

🏖️ Benefits

• health insurance benefits