Clinical Reviewer, Nurse Practitioner/Physician Assistant (Oncology)(Evening Hours preferred)

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 connect the pieces of a fragmented health care system to 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 the autonomy they need to get things done.

About the role

The Nurse Practitioner/Physician Assistant (ARNP/NP/PA) Oncology is responsible for supporting and assisting with all Oncology administrative and clinical utilization management and quality improvement functions under the auspices of the office of the Chief Medical Officer.

Responsibilities

• Conduct initial clinical review of incoming cases, rendering authorization approval based on established clinical criteria or escalating to a Field Medical Director if authorization cannot be approved during initial review.
• Act as a clinical liaison to providers, clients, and patients as directed by the office of the Chief Medical Officer.
• Engage in clinical conversations with providers and their office staff regarding medical necessity decisions.
• Maintain and operate Guideline Directed Treatment plans, including communicating with offices regarding treatment recommendations.
• Communicate the need for additional clinical information to ordering providers.
• Prepare cases that cannot be approved and which the provider will not modify or withdraw for peer-to-peer (P2P) discussions with Oncologists.
• Coordinate with Utilization Management (UM) staff to ensure timely and accurate communication of clinical decisions.
• Complete UM projects and participate in site visit reviews.
• Respect and maintain HIPAA confidentiality guidelines.
• Maintain availability to clinical and non-clinical administrative staff during performance of initial and second-level screening.
• Act as an interdepartmental liaison between all offices, departments, and committees.
• Serve as a subject matter expert and participate in meetings as assigned with practices and/or payers.
• Work with the Director of Clinical Operations to ensure client satisfaction.
• Perform all peer clinical review activities while located in a state or territory of the United States.
• Act with honor and integrity, serving as a role model for the company.
• Perform other duties as assigned.

Requirements

• Master of Science in Nursing or Doctor of Nursing Practice (DNP) degree from a recognized degree program OR a master's degree from a program accredited by the ARC-PA.
• Minimum of three (3) to five (5) years' experience in the practice of Oncology (required).
• Knowledge of regulatory requirements with at least two years of experience in a regulatory role (preferred).
• Current, unrestricted state PA or RN/NP license in medicine or required specialty.
• Licensed in home state.
• If a PA, obtaining a passing score on a national certifying exam.
• Obtaining and maintaining required licenses, per business need.
• A clinical license, active and in good standing, in your home state is required.

Skills

• Strong clinical, management, communication, and organizational skills.
• Demonstrated leadership skills.
• Analytic skills.
• Energetic and curious with a passion for quality and value in health care.
• Required to pass skills proficiency test.

Technical Requirements

All employees must have the following technical capability at their home:

• High-speed internet over 10 Mbps.
• For call center employees: the ability to plug in directly to the home internet router.

Pay

The expected base salary/wage range for this position is $68–$73 per hour.

Benefits

As part of our total compensation package, Evolent is proud to offer comprehensive benefits, including health insurance, to qualifying employees.