Appeals Nurse

Your Future Evolves HereEvolent Health has a bold mission to change the health of the nation by changing the way health care is delivered. Our pursuit of this mission is the driving force that brings us to work each day. We believe in embracing new ideas, challenging ourselves and failing forward. We respect and celebrate individual talents and team wins. We have fun while working hard and Evolenteers often make a difference working in everything from scrubs to jeans.Are we growing? Absolutely and Globally. In 2021 we grew our teams by almost 50% and continue to grow even more in 2022. Are we recognized as a company you are supported by for your career and growth, and a great place to work? Definitely. Evolent Health International (Pune, India) has been certified as “Great Places to Work” in 2021. In 2020 and 2021 Evolent in the U.S. was both named Best Company for Women to Advance list by Parity.org and earned a perfect score on the Human Rights Campaign (HRC) Foundation’s Corporate Equality Index (CEI). This index is the nation's foremost benchmarking survey and report measuring corporate policies and practices related to LGBTQ+ workplace equality.We recognize employees that live our values, give back to our communities each year, and are champions for bringing our whole selves to work each day. If you’re looking for a place where your work can be personally and professionally rewarding, don’t just join a company with a mission. Join a mission with a company behind it.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.What You Will Be Doing: 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. Researches 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.Qualifications Required and Preferred : 1-3 years' experience in clinical Appeals Review or Utilization Management Review and is an LPN or RN – Required and Preferred.

Must maintain a courteous and respectful disposition, and a positive, helpful attitude in all business settings. – Required

Must be able to exercise independent and sound judgment in clinical decision making - Required

Must be computer literate and able to navigate through internal and external computer systems- Required

Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities are a must – Required

Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally- Required

Strong written and verbal communication skills – Required

Mandatory Requirements:We require that all employees have the following technical capability at their home: High speed internet over 10 Mbps, the ability to plug in directly to the home internet router. These at-home technical requirements are subject to change with any scheduled re-opening of our office locations.​Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status .Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!