About Evry HealthEvry Health is seeking a tech-savvy Nurse to join our team. This is an exciting role allowing the ability to work with members across the continuum with ~75% utilization review and ~25% care coordination. Our teams are 100% virtual. While this is a remote role, you must reside in the United States and in the Eastern or Central time zone.Evry Health is on a mission to bring humanity to health insurance. Their high-technology health plans expand benefits, increase access and transparency, and feature a personalized, human approach.Evry Health is the major medical division of Globe Life (NYSE: GL). Globe Life has 16.8 million policies in force, and more than 3,000 corporate employees and 15,000 agents. For more than 45 consecutive years, Globe Life has earned an A (Excellent) rating or higher from A.M. Best Company.Roles and ResponsibilitiesPrepares clinical reviews based on clinical guidelines and provides monitoring of cases involving medical decisions and quality of care or service decisions; presents recommendations based on clinical review, criteria, and organizational policies to physician reviewers for final determination.Conducts prior authorization, concurrent, and retrospective reviews with emphasis on utilization management, discharge planning, care coordination, clinical outcomes, and quality of care by applying MCG guidelines, medical policy, and benefit structure for defined service requests.Monitors clinical quality concerns, makes referrals appropriately, identifies and escalates care quality issues, and quickly identifies outlier cases, long length of stay cases, or complicated prior authorization requests.Interacts with external facility or providers as needed to gather clinical information to support the medical necessity review process and plan of care.Assists departmental staff with issues related to coding, medical records/documentation, pre-certification, reimbursement, and claim denials/appeals.Uses active listening and motivational interviewing skills; handles difficult calls tactfully, courteously, professionally, and documents accordingly to build patient trust and engagement.Assesses and facilitates appropriate utilization of clinical programs and/or discharge planning by thoroughly assessing and screening for proper care coordination following discharge.Manages escalations within the department by ensuring appropriate accountability, sense of urgency, communication, and follow through to closure.Assists and facilitates working relationship with the Medical Director on CM and UM cases.Demonstrates personal responsibility and accountability by meeting attendance and schedule adherence expectations with positivity, enthusiasm, and helpful personality.Excels in a virtual work environment through active participation in team huddles, Supervisor 1:1s, Instant Messaging, or check-ins; efficiently answers and documents member/provider calls.Experience and Skills DesiredPrevious healthcare/managed care appeals experience.Must have a current, unrestricted Texas nursing license or Compact License; include your license number(s) and the corresponding state(s) in your resume.Diploma from an accredited school/college of nursing required.1–2 years of experience working at a health plan performing utilization management using standard practice guidelines.Working knowledge of medical and insurance industry terminology including basic level CPT/ICD-10, authorizations, digital health programs, NCQA/URAC standards.3–5 years of clinical experience in a hospital or ambulatory setting assisting with direct patient care.Passion for quality, teamwork, problem solving, and critical thinking.Ability to work independently and comfort in a fast-paced, deadline-oriented, tech-savvy work environment.Area of interest or experience within cardiology/pulmonology, women’s health, orthopedic surgery/physical medicine, primary care/pediatrics, and oncology.Experience outreaching and educating members telephonically.Innovative and entrepreneurial spirit with a passion to contribute to needed change in the health care system.Bonus: Familiarity with Salesforce/Healthcloud/CareIQ.Bonus: CCM or ACM certification, MCG certification.Bonus: Appeals experience.Telecommuting RequirementsThis is a remote position; the whole company works remotely. Company headquarters are in Dallas, Texas.Company business hours are weekdays 9–5 CST. Only candidates in the United States who reside in the CST or EST time zones will be considered. This position requires work during the stated business hours as well as rotating on-call weekends for utilization review cases.Required to have a dedicated work area separate from other living areas and that provides information privacy.Ability to keep all company sensitive documents secure.Must live in a location that receives an existing high-speed internet connection/service.Benefits PackageCompetitive salaryComprehensive health, dental, and vision insurance as well as life and disabilityRetirement savings plan with company matchGenerous time off/vacationProfessional development opportunitiesFlexible and remote work environment
