LEAD, UTILIZATION MANAGEMENT (RN)

Company: Evolent Health
Location: Des Moines
Posted on: October 26, 2024

Job Description:

Your Future Evolves HereEvolent 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:The Client Services team offers candidates the opportunity to positively impact member's care daily. Our clinical operations team possess a can-do spirit, as they will wear multiple hats throughout the day working through different scenarios to ensure members and providers receive decisions timely. We believe in creating opportunities for our staff to grow, so the candidate must be passionate about leading, coaching and motivating. We are a team of leaders who accomplish our mission through valuing people, providing resolutions, driving results, and collaborating with others.Collaboration Opportunities:The Lead Nurse of Utilization Management is responsible for assisting the UM Manager in supervising the operational productivity of the Utilization Management nurses by implementing and maintaining an efficient and effective flow of information through the UM department. The UM Lead, in collaboration with the UM Manager and Director, ensures compliance with all regulatory standards that include state, federal, NCQA and Health Plan, quality improvement programs. In addition, the UM Lead ensures all medically necessary services are reviewed according to appropriate criteria and/or policies.What You Will Be Doing:Provides day to day direction, expert operational and system knowledge and operational guidance to nurse staff in the UM department.In collaboration with the Manager and Director supports recruitment, interviewing, hiring and the successful on boarding of new UM personnel.Along with the Manager and Director, identifies and provides ongoing educational opportunities to staff, ensuring an understanding of business processes, technology, health care standards and guidelines and the impact on both the department and the organization.Identifies opportunities for training and staff development based on achievement of productivity/quality standards.Adjusts workflow responsibilities in line with staff expertise and availability.Ensures unit processes, identification and documentation of all health plan program requirements for performance improvement initiatives.In collaboration with the UM Manager and Director, assists in developing, implementing and communicating quantitative program actions that substantiate the value proposition and outcomes that effectively support these programs.Collaborates with UM Director and Quality Management to develop, implement and maintain UM policy and procedures, standard operating procedures and job aids.Works collaboratively across all departments to develop and foster synergistic communication, positive relationships and work processes that serve as a strong example of teamwork.Participates and leads appropriate unit meetings.Respects and maintains HIPAA confidentiality guidelines.Acts as an interdepartmental liaison between all Evolent offices, departments, and committees.Performs other duties as assigned.QUALIFICATION REQUIRED:RN Licenses (Active and Unrestricted)Associate's degree or equivalent years of work experience.1-2 years of experience working with a global workforce and a working knowledge of clinical quality metrics such as HEDIS and NCQA preferred.2 - 4 years of operations and Utilization Management experience in a population management or managed care/insurance or hospital medical management department setting may be substituted for associate degree. Experience in consulting or services organizations with a proven ability to manage client relationships and achieve change within another organization preferred.Experience with clinical decision-making criteria sets (i.e., Milliman, InterQual)Strong interpersonal, oral, and written communication skills.Possess basic computer skills.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 recruiting@evolent.com for further assistance.The expected base salary/wage range for this position is $40.00 up to $44.00 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.Don't see the dream job you are looking for? Drop off your contact information and resume and we will reach out to you if we find the perfect fit!For more insights about Evolent Health, click on Life At Evolent (https://www.evolent.com/) to learn more!

Keywords: Evolent Health, Des Moines , LEAD, UTILIZATION MANAGEMENT (RN), Executive , Des Moines, Iowa