Appeals Nurse

Your Future Evolves Here at Evolent

Evolent partners with health plans and providers to achieve better outcomes for people with the most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of a 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 the 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.

About the Appeals Nurse Role

The Specialty Appeals Team offers candidates the opportunity to make a meaningful impact as part of a highly trained, dedicated team focusing on appeals and post-determination requests. We maintain the principles of utilization management by adhering to Evolent and Client policies and procedures while complying with timeliness guidelines. Our team values collaboration, continuous learning, and a customer-centric approach, ensuring that every team member contributes to providing better health outcomes for the Clients and Members we serve.

Collaboration Opportunities

The Specialty Appeals Nurses work with a group of nurses, providing appeal intake review for one dedicated client. They interact with coordinators who set up the appeal, Physicians and other Clinicians who review the appeal, and managers for direction and leadership. The Appeals teamwork strategies and opportunities for collaboration include all-team and individual team meetings, Teams chats, and monthly communication on team metrics and accomplishments.

What You Will Be Doing

• Practices and maintains the principles of utilization management and appeals management by adhering to company policies and procedures.
• Documents communications with medical office staff and/or MD provider as required.
• Interfaces with other departments to satisfactorily resolve issues related to appeals and retrospective reviews.
• Provides optimum customer service through professional and accurate communication while maintaining accreditation and health plan's required timeframes.
• Refers cases to appropriate internal reviewers according to the business needs of the particular health plan.
• Reviews requests for Urgent appeals compared to expedited criteria for downgrade to Standard processing, documenting accordingly.
• Works closely with the appeals-dedicated Clinical Reviewers to ensure timely adjudication of processed appeals.
• Other duties as assigned.

Qualifications Required and Preferred

• 1-3 years' experience as an RN - Required
• Minimum of 5 years in Utilization Management, health care Appeals, compliance and/or grievances/complaints in a quality improvement environment - Required
• Able to work in a rotation to work 10:30am to 7pm CST (which includes 30-minute unpaid lunch break) 3 days/week, to meet the business needs of nurses providing coverage until 7:00pm CST - Required
• Must be able to exercise independent and sound judgment in clinical decision making - Preferred
• Able to navigate through internal and external computer systems. Working knowledge of Microsoft Office Product Suite - Preferred
• Strong organizational and effective time management skills; demonstrated ability to manage multiple priorities - Preferred
• Outstanding interpersonal and negotiation skills to effectively establish positive relationships both internally and externally, including strong written and verbal communication skills - Preferred

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.

Compensation and Benefits

The expected base salary/wage range for this position is $37-$42/hr. 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.

Key skills/competency

• Utilization Management
• Appeals Management
• Clinical Review
• Compliance
• Customer Service
• Documentation
• Health Plan Policies
• Collaboration
• Time Management
• Negotiation Skills