Utilization Management Clinician Job Vacancy in Evolent Health Pune, Maharashtra – Updated today

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Full Details :
Company Name : Evolent Health
Location : Pune, Maharashtra
Position :

Job Description : It’s Time For A Change…
Your Future Evolves Here
Evolent 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 in everything from scrubs to jeans.
Are we growing? Absolutely – about 40% in year-over-year revenue growth in 2018. Are we recognized? Definitely. We have been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019, and one of the “50 Great Places to Work” in 2017 by Washingtonian. 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:
Position Summary
The Nurse Reviewer is responsible for performing precertification, prior approvals, labor and delivery admission and discharges. Tasks are performed within the LVN/LPN scope of practice, under Medical Director direction, using independent nursing judgement 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.
You must have or be able to obtain an Illinois Nursing License for this position.
Roles and Responsibilities:
Performs utilization review of outpatient procedures and ancillary services.
Fulfils on call requirements for selected clients as scheduled.
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 UM Leadership.
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.
Availability on some weekends and holidays may be required
Performs other duties as assigned.
Mandatory Skills
Active, Medical Doctor, Doctor of Osteopathic Medicine, or equivalent license
Bachelor’s degree in a medical field
UM Experience preferred
Minimum of three years of direct clinical patient care
Minimum of one year of experience with medical management activities in a managed care environment
Knowledge of managed care principles, HMO and Risk Contracting arrangements.
Knowledge of health care resources within the community
Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)
Strong interpersonal, oral and written communication skills.
Possess basic computer skills
Willingness to commit to alternative schedule outside of Mon Friday 9-5 central to include Saturdays County care specific- Prefer Illinois license, however if out of state, will need to be initiated immediately upon hire and be licensed within first 90 days (exception if the delay is beyond the candidate’s control and related to State of Illinois delay)

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