Healthcare & Clinical
Utilization Review Nurse
Remote, United States

It’s Time For A Change…

Your Future Evolves Here

At New Century Health we are pioneering a new era of specialty care, focused on engaging with payers and providers to improve the quality of care for patients diagnosed with cancer and heart disease. Our evidence-based care delivery model supports patients during their most vulnerable times, a responsibility we are both humbled by and passionate about. 

With nearly two decades of proven results in Oncology and Cardiovascular care, New Century Health improves quality and lowers costs for the 6M+ patients whose care we manage. Our approach is based on a proven clinical model that engages Oncology and Cardiovascular specialists through value-based care delivery. We believe the highest quality care is also the lowest cost care over time, improving outcomes and delivering financial savings to our partners. The New Century Health model has been proven across Medicare, Medicaid, and Commercial populations. New Century Health joined the Evolent Health family in 2018, joining the mission to change the health of the nation.   

Are we growing? Absolutely. We have seen about 30% average growth over the last three years. Are we recognized? Definitely. We were named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts.  Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign's Corporate Equality Index, was named on the Best Companies for Women to Advance List 2020 by, and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. 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:

  • Reviews Provider request for relevant and complete supporting documentation.
  • Requests additional documentation per New Century Health (NCH) policy.
  • Utilizing clinical guidelines approved by NCH Utilization Management Committee (UMC), the URN has the authority to authorize services or procedures. If a request does not meet established clinical guidelines for appropriateness and medical necessity, the request is sent to a physician reviewer. At no time can a URN recommend an adverse determination.
  • Ensures regulatory guidelines are met for timeliness and use of medical review criteria.
  • Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
  • Establishes and maintains professional relationships with Providers and office staff for the purpose of education to establish a smooth operational flow of authorizations and referrals.
  • Educates and supports UM staff with medication requests, laboratory results and documentation of submissions per approved NCH policy guidelines.
  • Complies with current URAC standards as they relate to this position.
  • Supports clinical initiatives as identified by the UM department and UMC.
  • Assists Chief Medical Officer (CMO), Medical Reviewers and the Clinical Specialist in the submission of developed and approved pathways sent to Information Technology.
  • Assists the Director of UM, Medical Reviewers and CMO to develop report data elements necessary to track and trend utilization practices by provider, practice variation reports, reports to support quality initiatives, and elements to support NCH dashboard reports.
  • Acts with honor and integrity, serving as a role model for the company.
  • Complies with HIPAA requirements and all NCH policies and procedures.
  • Acts as an interdepartmental liaison between all NCH offices, departments, and committees.
  • Performs other duties as assigned.

The Experience You'll Need (required):
To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel.
  • Able to work in a fast-paced environment, demonstrate excellent problem solving, critical thinking, and organizational skills.
  • Performs multiple tasks efficiently and accurately, have exceptional attention to detail and perform consistent work product validation/QA.
  • Self-motivated, self-directed, team oriented, and responsible, with a positive attitude and a proactive style. Possesses the ability to operate in a highly variable work environment.
  • Presents a courteous and competent demeanor to our clients and teammates.
  • Bachelor’s degree in Nursing or HealthCare related field preferred. Unrestricted Registered Nurse (RN), LPN or LVN license required for the state of employment.
  • Excellent customer service skills
  • Strong computer skills in MS Excel and Word.
  • Ability to easily navigate through website research.
  • Ability to work nights and weekends, as necessary.
Finishing Touches (preferred):
  • 2 - 4 years UM experience preferred.
  • 2 - 3 years in an inpatient or outpatient setting highly preferred.
  • Specialty certification preferred.
  • Ability to review medical records and identify codes for claims processing preferred.
  • Oncology and/or cardiology experience highly preferred.

Evolent Health is an equal opportunity employer and considers all qualified applicants equally without regard to race, color, religion, sex, sexual orientation, gender identity, or national origin.

Technical requirements:

Currently, Evolent employees work remotely temporarily due to COVID-19. As such, we require that all employees have the following technical capability at their home: High speed internet over 10 MBPS and, specifically for all call center employees, 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.

Job Alerts