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Evolent Health UR Denial Nurse in Des Moines, Iowa

Your Future Evolves Here

New Century Health (NCH) has been transforming the delivery of specialty care and driving radical cost and quality improvement across the member journey for patients with cancer and cardiovascular disease. As part of Evolent Health, we are on a bold mission to change the health of the nation by changing the way health care is delivered. Evolenteers make a difference wherever they are, whether it is at a medical center, in the office, or while working from home across 48 states. We empower you to work from where you work best, which makes juggling careers, families, and social lives so much easier. Through our recognition programs, we also highlight employees who live our values, give back to our communities each year, and are champions for bringing their 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.

Why We’re Worth the Application:

  • We continue to grow year over year.

  • Recognized as a leader in driving important diversity, equity, and inclusion (DE&I) efforts (https://www.evolenthealth.com/diversity) .

  • Achieved a 100% score two years in a row on the Human Rights Campaign's Corporate Equality Index making us a best place to work for LGBTQ+ equality.

  • Named to Parity.org’s 2020 list of the best companies for women to advance (https://www.evolenthealth.com/about-us/press-releases/8579/evolent-health-named-to-parity.org%E2%80%99s-best-companies-for-women-to-advance-list-2021) .

  • Continued to prioritize the employee experience and achieved an 87% overall engagement score on our last employee survey.

  • Published an annual DE&I report (https://dev.evolenthealth.com/sites/default/files-public/Evolent%20Health%202020%20DE%26I%20Annual%20Report.pdf) to share our progress on how we’re building an equitable workplace.

What You’ll Be Doing:

What You’ll Be Doing:

Under the direction of Supervisor of Denial Management, the position will be responsible for the day-to-day reviews and documentation within clinical Denials Team in support of national operations. The primary responsibility is to perform the medical necessity review of drug therapy including but not limited to chemotherapy and other supportive agents. Using evidence-based medicine, the Denial Nurse will determine if chemotherapy or other drugs can be approved or if escalation to a Peer Clinical Reviewer is required. The Denial Nurse plays a key role in reviewing pertinent clinical data needed to make a determination within the time limits specified by CMS or per contractual agreements. The Denial nurse ensures the denial department provides subject matter expertise around clinical prior authorization denial management.

KNOWLEDGE, SKILLS & ABILITIES

Responsibilities include:

  • Reviews pre-certification/prior approval, denials and determines appropriateness of denial based upon regulatory guidelines, professional judgment, and compendia/or NCH policy,

  • Works in collaboration with CarePro team to create, and QA member level denial letters for accuracy,

  • Promotes a strong culture of accountability, teamwork, collaboration, and operational excellence,

  • Demonstrates an understanding of technical and clinical denials areas, such as: medical necessity, eligibility issues, no authorization, continuation of care,

  • Application of clinical guidelines such as CMS Guidelines, Health Plan Policy, drug Compendia, and health plan step therapy/preferred drug guidelines,

  • Ensures that service levels and department key performance indicators are met consistently

  • Demonstrated ability to problem solve complex situations,

  • Strong organizational, task prioritization, resource management skills,

  • Intermediate computer literacy on Microsoft Office products and web browsing,

  • Ability to decipher clinical data and medical terminology,

  • Application of clinical guidelines such as CMS Guidelines, Health Plan policy and drug Compendia,

  • Troubleshooting skills and conflict resolution techniques,

  • Confident clinical decision making,

  • Rigorous attention to detail,

  • Comfortable with the possibility of talking to members/providers if there are questions or concerns,

  • Familiarity with writing complex clinical explanation into an easy-to-understand language

The Experience we Require:

  • Nursing License LPN/RN

Finishing Touches (Preferred):

  • Ability to make effective decisions as well as the ability to work remotely

  • Excellent written and oral communication & presentation skills

  • Strong organizational, and close attention to detail and accuracy

  • Computer knowledge with all Microsoft suites

  • Must be flexible and comfortable with ambiguity and change.

  • Experience with multiple chronic conditions-with a focus on Oncology and Cardiology

  • Experience in the healthcare industry preferably in utilization management preferably with health insurance / health plan experience

  • Minimum 1 years of pre-certification/prior approval clinical denial unit management experience

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, 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 committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and national law regarding COVID health and vaccination requirements. Evolent expects all employees to also comply. We currently require all employees who may voluntarily return to our Evolent offices to be vaccinated and invite all employees regardless of vaccination status to remain working from home.

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.

Compensation Range: The minimum salary for this position is $$37/hr, plus benefits. Salaries are determined by the skill set required for the position and commensurate with experience and may vary above and below the stated amounts.

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