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Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and 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 autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

Our shared services team offers candidates the opportunity to make a meaningful impact by providing exceptional support to internal and external customers through positive interactions, and timely delivery of high-quality products. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes.

Collaboration Opportunities:

+ Works with the physician reviewer to monitor the adverse determination process and ensure notification timeframes are met

+ Works with internal and external staff to ensure that decisions are made, documented, and communicated clearly

What You Will Be Doing:

The Clinical Letter Writer is responsible for reviewing adverse determination decisions against criteria and policy, escalating questions to the physician reviewer, and creating letters that meet regulatory and Plain Language requirements. This position requires a person who can synthesize various clinical and administrative requirements, communicate well with the team and clients, and write clearly.

+ Reviews adverse determinations against criteria and medical policies

+ Creates adverse determination notifications that meet all accreditation, State, and Federal criteria

+ Uses Plain Language and good written skills to clearly communicate adverse decisions to both members and providers

+ Appropriately identifies and refers quality issues to the Senior Director of Medical Management or Medical Director.

+ Appropriately identifies potential cases for Care Management programs

+ 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: Required and Preferred:

+ Licensed registered nurse or LVN/LPN (current and unrestricted)

+ Minimum of three years of direct clinical patient care

+ **Minimum one year of experience with Utilization Review (UM) in a managed care environment**

+ **Cardiology and Oncology Healthcare** **experience/knowledge**

+ Excellent written communication skills

+ Experience with clinical decision-making criteria sets (i.e. Milliman, InterQual)

+ Strong interpersonal, oral, and written communication skills.

+ Possess basic Microsoft Office computer skills

+ Knowledge of managed care principles, HMO and Risk Contracting arrangements a **plus but not required**

• **This role is Monday- Friday from 9:00 am to 6:00pm EST, CST or PST. Additionally rotating weekends, on-call and holidays.**

Technical Requirements:

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.

Evolent 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.** **If you need reasonable accommodation to access the information provided on this website, please contact** **[email protected]** **for further assistance.

The expected base salary/wage range for this position is $31.00 to $34.00 per hour. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.

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