Job description
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.
- Achieved a 100% score two years in a row on the
Human Rights Campaign's Corporate Equality Indexrecognizing us as a best place to work for LGBTQ+ equality.
- Named to Parity.org’s list of the best companies for women to advance for
3 years in a row(2020, 2021 and 2022).
- Continue to prioritize the employee experience and achieved a 90% overall engagement score on our employee survey in May 2022.
- Publish an annual
DE&I reportto share our progress on how we’re building an equitable workplace.
What You’ll Be Doing:
Directs daily involvement in the following utilization management functions:
- Reviews all cases in which Hematology & Medical Oncology clinical determinations cannot be made by the Initial Clinical Reviewer.
- Serves as the specialty match reviewer in Hematology & Medical Oncology cases as well as other requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert licensed/board certified in that area.
- Discusses determinations with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request by phone or fax.
- Provides clinical rationale for standard and expedited appeals.
- Provides assistance and act as a resource to Initial Clinical Reviewers as needed to discuss cases and problems.
- Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process so as to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as URAC and NCQA guidelines.
- Ensures documentation of all communications with medical office staff and/or MD provider is recorded in a timely and accurate manner.
- Participates in on-going training per inter-rater reliability process.
- Assists the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
- On a requested basis, reviews appeal cases and/or attends hearings for discussion of utilization management decisions.
- On a requested basis, may function as Medical Director for select health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director.Doctor of Medicine (MD) degree OR Doctor of Osteopathic Medicine (DO) degree OR Bachelor of Medicine, Bachelor of Surgery (MBBS) international degree with successful completion of United States based internship and residency (and successful completion of United States based fellowship for subspecialists) required.
Requirements:
- Current, unrestricted license to practice medicine in one or more states of the United States.
- Board Certified by one of the American Board of Internal Medicine or American Board of Osteopathic Internal Medicine (ABIM/ABOIM).
- A licensed Physician practicing in a specialty such as: Hematology or Oncology.
- A minimum two-year fellowship is required for completion of training in either hematology or oncology. The third year of fellowship is required for certification in both subspecialties.
- Familiarity with the principles and procedures of utilization management as practiced in managed care organizations, experience with cost benefit analysis, quality assurance and the continuous quality improvement process is desirable.
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 $-, 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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