Oncology Clinical Review Nurse in Dover, DE

Your Future Evolves Here Evolent is on a mission to partner with health plans and providers to enhance outcomes for individuals battling complex and high-cost health conditions. We aim to bridge the gaps in the healthcare system, ensuring our patients receive the same level of care and compassion that we would want for our loved ones. At Evolent, we prioritize work/life balance, offering flexibility that allows you to tailor your work to fit your lifestyle, along with the autonomy to excel in your role. We believe that fostering an environment where everyone can bring their authentic selves to work is vital. This commitment to diversity and inclusion is at the core of our values. What You'll Be Doing: The Oncology Clinical Review Nurse will conduct precertification and prior approval assessments. Operating within the scope of RN/LVN/LPN practice and guided by the Medical Director, you will utilize independent nursing judgment alongside physician-developed medical policies and clinical decision-making criteria. Your role will focus on advocating for patients while ensuring seamless care delivery and high-quality, cost-effective services. • Conduct pre-certification utilization reviews of Oncology treatment requests. • Assess medical necessity and service appropriateness using established clinical review criteria. • Document all review rationales and determinations accurately. • Identify and refer cases not meeting clinical criteria to the Medical Director. • Flag quality issues for UM Leadership. • Collaborate with physicians and providers to facilitate service delivery across the healthcare continuum. • Ensure accurate data entry and communication of relevant information to team members. • Engage in continuing education initiatives to maintain your expertise. • Be available for occasional weekend or holiday shifts. • Undertake other duties as assigned. The Experience You'll Need (Required): • Current, unrestricted license as a Registered Nurse or Licensed Practical/Vocational Nurse. • High School Diploma or equivalent. • A minimum of three years of direct clinical patient care experience in acute, inpatient, or critical care settings, with a strong preference for direct Oncology experience. • Proficient computer skills, including familiarity with MS Office Suite. • Excellent interpersonal, oral, and written communication skills. • Willingness to participate in weekend holiday rotation. Finishing Touches (Preferred): • Experience with clinical decision-making criteria sets (such as Milliman or InterQual). • At least one year of experience in medical management within a managed care environment. • Experience in Utilization Management/Utilization Review. • Clinical background in Oncology, ICU, ED, or similar critical care environments. • Previous remote work experience. To maintain a secure hiring process, candidates will undergo identity verification steps, including providing a government-issued photo ID. Background checks, in-person I-9 verification, and potential drug screening are required prior to employment. Please note, the use of AI tools during interviews is prohibited and closely monitored. Any misrepresentation will lead to immediate disqualification from consideration. Technical Requirements: All employees must have high-speed internet service of at least 10 Mbps, particularly for call center roles, which require a direct connection to the home internet router. Please be aware that these technical requirements may change in alignment with any reopening of our office locations. Evolent is an equal opportunity employer, considering all qualified applicants without discrimination based on race, color, religion, sex, sexual orientation, gender identity, national origin, veteran status, or disability status. If you need reasonable accommodation to access any information on our website, please reach out for further assistance. The expected base salary for this position ranges from $32 to $37 per hour. This role is also eligible for a performance-based bonus. As part of our total compensation package, we offer comprehensive benefits, including health coverage, to qualifying employees. All salary determinations take into account the skills, experience, and requirements for the position, which may vary based on individual circumstances. If you don't see your dream job listed, please share your contact information and resume. We will reach out if an opportunity fitting your skills arises!