Evolent Health Director, UM in Boston, Massachusetts
This is an unique opportunity to improve the health and wellbeing of millions of Americans!
Founded in 2002, New Century Health has been on the cutting edge of value-based innovation for decades as the nation's foremost specialty care management company, specializing in managing cancer and cardiology patients for both payers and risk-based providers. Formerly backed by Water Street Partners, the company was acquired by Evolent Health in 2018 and has scaled tremendously since.
Specifically, New Century Health provides physicians with clinical decision and population health management tools to ensure that their patients receive the highest quality, most affordable care. These best-in-class tools, which have earned the business URAC accreditation in Health Utilization Management and NCQA accreditation in Utilization Management, consistently drive clinical and financial improvements for the two most complex and expensive diseases in the nation. This commitment to excellence has helped spur our success and put us on track to surpass record-breaking year-over-year growth in the coming years.
What You’ll Be Doing:
Leadership of utilization management activities including design and implementation of the operations. Activities may include training, prior authorization, concurrent review, intake, appeals and grievances for clients who have delegated UM.
Monitor all activities related to medical review. Develop on-site processes where indicated with direct oversight of centralized telephonic review process of all necessary utilization management components.
Partner with leadership to mentor staff. Jointly develop goals, objectives and define major roles. Implement processes, procedures and accountabilities for staff.
Responsible for achieving targeted utilization management results established by the department and/or client by monitoring and reporting the utilization management resources, implementing initiatives and educational processes.
Develop and adopt best practice methodologies and training programs for utilization management tools and techniques.
Provide recommendations on staffing plans, and assuring adequate allocation of resources for UM functions, and coordinating needs with market clinical leadership.
Collaborate with IT and Analytics teams for the development of required utilization management monitoring, initiatives, patient engagement and other outcomes initiatives.
Collaborate with other functional areas that interface with the utilization management department, including but not limited to claims, appeals, product, network development and care management.
Provide appropriate and timely management of complex clinical issues.
Mentor and support ongoing training and development of staff.
Promote a positive work environment by providing timely, specific and constructive performance feedback.
All other duties as assigned.
The Experience You Need (Required):
Active license as Registered Nurse (RN, RNC)
Working knowledge of activities such as prior authorization, concurrent review, intake, appeals and grievances
Five (5) to seven (7) years of progressive experience in utilization management in a health plan
Associate’s Degree or equivalent Diploma in Nursing or related healthcare field, Bachelor’s Degree in Nursing or related healthcare field preferred (with Master’s Degree in Nursing or Business Administration/Hospital Administration/ Public Health strongly preferred)
Finishing Touches (Preferred):
- Experience working within a provider owned health plan or a risk bearing provider organization
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 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 Health is committed to the safety and wellbeing of all its employees, partners and patients. 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.
As we continue to evaluate re-opening our offices more fully and begin to have specific roles that will require face to face interaction with our providers and patients in client facilities or homes, all employees must be prepared to meet our vaccine requirements with or without accommodation at that time.”
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.
Evolent allows employees to work remotely for many of our positions. For those working remotely, 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.
Evolent Health is committed to the safety and wellbeing of all its employees, partners and patients and complies with all applicable local, state, and federal 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. Certain jobs require face-to-face interaction with our providers and patients in client facilities or homes. Employees working in such roles will be required to meet our vaccine requirements without exception or exemption.
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. Evolent Health maintains a drug-free workplace. Evolent has been named one of “Becker’s 150 Great Places to Work in Healthcare” in 2016, 2017, 2018 and 2019 and are proud to be recognized as a leader in driving important Diversity and Inclusion (D&I) efforts. Evolent achieved a 95% score on its first-ever submission to the Human Rights Campaign's Corporate Equality Index, was named on the Best Companies for Women to Advance List 2020 by Parity.org, and we publish an annual Diversity and Inclusion Annual Report to share our progress on how we’re building an equitable workplace. We recognize employees that live our values, give back to our communities each year, and are champions for bringing our 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.
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