Cardiology Physician Clinical Reviewer

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. 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 Index recognizing 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 report to share our progress on how we’re building an equitable workplace.

What You’ll Be Doing:

Do you crave an exciting new job that allows you to use your years of clinical expertise while developing new skills and improving the lives of others? If so, then this is the fit for you. As a Cardiac Physician Clinical Reviewer, you’ll use your clinical knowledge to provide evidence-based Cardiology reviews for patient care. You will be a key member of the utilization management team and routinely interact with physicians, leadership, management staff and other Physician Clinical Reviewers (PCR’s) whenever a physician`s input is needed or required.

We provide you with all the computer equipment and training needed to be successful in this role. And the best part, you get to reap the benefits of a work-from-home role. If you are looking for a better work life balance, we offer that at Evolent. We offer part-time and full-time roles, so that you can choose a schedule that works best for you!

Job Summary:

• Serve as the specialty match reviewer in Cardiac cases, that do not initially meet the applicable medical necessity guidelines, as well as other imaging requests when providers, clients, or state laws require specialty reviews to be completed by the subject matter expert.
• Discusses determinations (peer to peer phone calls) with requesting physicians or ordering providers, when available, within the regulatory timeframe of the request.
• Provides clinical rationale for standard and expedited appeals.
• Utilizes medical/clinical review guidelines and parameters to assure consistency in the MD review process to reflect appropriate utilization and compliance with SBU`s policies/procedures, as well as Utilization Review Accreditation Commission (URAC) and National Committee for Quality Assurance (NCQA) guidelines.
• Aids and acts as a resource to Initial Clinical Reviewers.
• 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.
• May assist the Senior Medical Director in research activities/questions related to the Utilization Management process, interpretation, guidelines and/or system support.
• On a requested basis, may function as Medical Director for selecting health plans or regions, assuming overall accountability for utilization management while working in conjunction with the Senior Medical Director.
   

The Experience You’ll Need (Required):

• DO/MD/MBBS Degree
• Board Certified by an American Certifying Board for the specialty of Cardiology or a subspecialty in Cardiology.
• Current, Unrestricted License