UM Nurse (Oncology/ICU)

Its Time For A Change

Your Future Evolves Here

Evolent 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 in everything from scrubs to jeans.

Are we growing Absolutely56.7% in year-over-year revenue growth in 2016. Are we recognized Definitely. We have been named one of Beckers 150 Great Places to Work in Healthcare in 2016 and 2017 and one of the 50 Great Places to Work in 2017 by Washingtonian and our CEO was number one on Glassdoors 2015 Highest-Rated CEOs for Small and Medium Companies. If youre looking for a place where your work can be personally and professionally rewarding dont just join a company with a mission. Join a mission with a company behind it.

UTILIZATION MANAGEMENT NURSE

What Youll Be Doing:

The UM Nurse is responsible for performing precertification prior approvals concurrent and retrospective reviews and coordination of discharge planning. Tasks are performed within the scope of practice under Medical Director direction using independent clinical judgment and decision-making physician-developed medical policies and clinical decision-making criteria sets. Acts as a member advocate by expediting the care process through the continuum working in concert with the health care delivery team to maintain high quality and cost-effective care delivery.

Roles and Responsibilities:

• Performs utilization review of outpatient procedures and ancillary services
• Determines medical necessity and appropriateness of services using clinical review criteria
• Accurately documents all review determinations and contacts providers and members according to established timeframes
• Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director
• Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director
• Appropriately identifies potential cases for Care Management programs
• Collaborates with physicians and other providers to facilitate 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
• Collaborates with Claims Quality Management and Provider Relations Departments as requested
• Performs other duties as assigned

Qualifications:

• An active and unrestricted Nursing License in the Philippines and in US (PHRN and USRN)
• At least two (2) years of prior acute care experience Oncology or Intensive Care- Must have
• One (1) years experience with Utilization Management (UM) Review particularly in a Managed Care environment. Equivalent work in Oncology UM is desirable.
• Knowledge of managed care principles HMO and Risk Contracting arrangements - Preferred
• Preferred experience with clinical decision-making criteria sets (i.e. Milliman InterQual)
• Demonstrated ability in using computer and Windows PC applications which includes strong keyboard and navigation skills
• Must possess good written and oral communication skills organizational skills; be proficient in decision making problem solving and time management.
• Typing speed of >45 words per minute preferred.
• Ability to multitask in a fast-paced environment
• Proficient in MS Outlook Word and Excel and general computer literacy working with dual screens
• Ability to maintain strict confidentiality of protected health information
• Willing to work any assigned shift during a week in Makati Cityper schedule and business needs

All qualified applicants will receive consideration for employment without regard to race color religion gender gender identity sexual orientation national origin ethnicity age disability marital status or any other characteristic protected by law.

Genfinity as an Equal Opportunity Employer believes in each persons potential and well help you achieve yours.

All information will be kept confidential according to EEO guidelines.

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