Clinical Reviewer, Radiation Therapy

• To ensure the appropriate utilization of services act as an advocate for our members and to ensure the highest quality and cost-effective care.
• Collaboration

Opportunities: As a Radiation Technologist in the Utilization Management department, you will work closely with other nurses, managers, medical directors, and upper leadership as requested.

• Reviews Provider request for relevant and complete supporting documentation and requests for missing or additional documentation from providers per guidelines.
• Utilizing clinical guidelines approved by the Utilization Management Committee (UMC), the URN has the authority to authorize services or procedures.
• If a request does not meet established clinical guidelines for appropriateness and medical necessity, the request is sent to a physician reviewer.
• At no time can a URN recommend an adverse determination.
• Verifies accuracy of codes and services and applies them accurately with appropriate documentation.
• Ensures regulatory guidelines are met for timeliness and use of medical review criteria.
• Acts with honor and integrity, serving as a role model for the company while establishing and maintaining professional relationships with Providers and office staff.
• Complies with HIPAA requirements and all Evolent policies and procedures.
• Performs other duties as assigned including and not limited to develop report data elements.

Requirements

• American Registry of Radiologic Technologists (ARRT) certification is current and in good standing in your home state. (Required)
• Possesses effective verbal/written communication skills, especially via phone, with the ability to interact with various levels of personnel. (Required)
• Able to work in a fast-paced environment, and demonstrate excellent problem-solving, critical thinking, and organizational skills. (Required)
• Strong computer skills in Microsoft Office programs as well as EMR, Share Point, and website navigation and email organization. - Required
• Required shift of 9:30AM - 6:00PM PST M-F, occasional weekends and holidays required with advance scheduling. - Required
• 2 - 4 years UM experience - Preferred
• Core Competencies

Demonstrates expertise in Utilization Management, ensuring compliance with clinical guidelines and regulatory standards while effectively communicating with healthcare professionals.

Proficient in coding accuracy and documentation, with a strong commitment to quality care and member advocacy.

Certifications & Qualifications

• ARRT Certification
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