Role Description The Clinical Reviewer (RN) evaluates medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care. This position documents decisions and rationale and communicates results with stakeholders through various means providing education and guidance. Essential Functions - Reviews, researches, and analyzes medical records and other documentation to determine compliance with regulations, guidelines, and standards of care. - Applies accurate, independent coverage and payment decisions using consistent evaluation standards. - Communicates decisions and provides associated education to stakeholders using various methods. - Determines recommendations for actions based on analysis of review results. - Prioritizes workload depending on business need and direction. - Identifies and communicates potential fraud, waste, and abuse using established work instructions. - Collaborates and communicates with peers and leaders. - Participates in team quality and calibration review processes. - Serves as a mentor to peers. - May prepare documents for, and participate in, legal hearings. Qualifications - Current, active, unrestricted RN license in state of practice - 2 years' clinical experience - 1 year Microsoft Office experience - Strong verbal and written communication skills - Strong computer experience Requirements - Bachelor's degree in Nursing (BSN, BAN, etc.) - 1 year experience evaluating medical records applying clinical expertise to determine compliance with applicable guidelines and standards of care - 1 year experience in utilization review or case management - 1 year experience educating external customers - 1 year experience leading projects, initiatives, or processes - Strong prioritization, problem solving, and organizational skills - Strong attention to detail - Knowledge of coding - Microsoft proficiency - Strong business writing experience Benefits - Health, Dental and Vision Insurance - Voluntary Insurance Plans - Health Savings and Flexible Spending Accounts - 401k and Company Match - Company-paid Life Insurance - Education Assistance Program - Paid Sick Leave - Paid Holidays - Increasing PTO Accrual Plan - Medical/Parental/Disability Leave - Workers Compensation - Retiree Benefits - Severance Package - Employee Assistance Program - Financial and Health Wellness Benefits - Casual Dress - Open Office Setting - Online Learning System

Role Description The role of the Psychologist Peer Review for ALERT involves applying clinical criteria and benefit plan requirements to Commercial, Medicaid, and Medicare cases, and making clinical and/or benefit determinations to continue coverage of treatment, shaping and modifying treatment as appropriate, or issuing an adverse benefit determination if applicable criteria is not met. You’ll enjoy the flexibility to work remotely from anywhere within the U.S. as you take on some tough challenges. Primary Responsibilities: - Standard outpatient treatment, including requests for extended length sessions or single case agreements - State-specific Medicaid services (e.g. Psychosocial Rehabilitation, Targeted Case Management, Home Based Habilitation, Supported Employment, etc.) - Intensive Outpatient services for both Mental Health and Substance Abuse - Participate in peer consultations, staff meetings, and trainings; entering determinations within federal, state, and local guideline requirements; and perform other duties as required by the reviewer’s manager - Conduct Non-MD clinical reviews of the following type during a typical workday: - Requests for psychological or neuropsychological testing - Review of outpatient treatment plans for services that are sent for Peer Review that do not appear to meet clinical criteria and/or when there are concerns about the quality of care - Review of ongoing outpatient care in cases where the member’s treatment episode exceeds normative standards - Requests for non-standard outpatient services (extended-length visits, an in-network accommodation, intensive outpatient program with no MD involvement) - Appeals of previously denied services or claims for outpatient non-MD services up to and including Intensive Outpatient Programming You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in. Qualifications - Licensed doctoral level (Ph.D. or Psy.D.) Psychologist - License must be current, allow for full independent practice, and be unrestricted (you may be asked to obtain additional state licenses to meet growing business needs) - 3+ years of post-licensure experience - Experience working with insurance agencies - Computer skills, including facility with Windows OS, Outlook, Word, and Excel - Proven ability to type proficiently while speaking on the phone Requirements - Experience working in a managed care setting - Experience performing Peer Reviews - Experience with commercial, Medicaid and Medicare lines of business - Experience with CPT and HCPC codes - Clinical experience in higher levels of care (Intensive Outpatient) - Clinical experience with children and adolescents - Clinical experience with Substance Abuse diagnoses - Clinical experience with Evidence-Based Treatment - Advanced computer skills using Excel and Access Databases - Proven solid organizational and time management skills, with the ability to prioritize multiple demands within strict turn-around-time requirements - Proven solid written and verbal communication and negotiation skills - Proven ability to work well independently and collaborate with others on a clinical team - Proven ability to enjoy a fast paced, changing environment - Candidates located in Mountain or Pacific Time Zones Benefits - Comprehensive benefits package - Incentive and recognition programs - Equity stock purchase - 401k contribution (all benefits are subject to eligibility requirements) Application Deadline This will be posted for a minimum of 2 business days or until a sufficient candidate pool has been collected. Job posting may come down early due to volume of applicants.

• Create and maintain client profiles by accurately inputting information into the client's system • Work closely with clinical staff to retrieve necessary information required for processing patient claims • Verify the completeness and accuracy of client information, make necessary updates, and review and analyze claim documentation for compliance with established guidelines and requirements • Maintain confidentiality and handle sensitive information by established protocols • Assist in the development and implementation of process improvements to enhance efficiency and quality • Maintain effective working relationships with colleagues using appropriate interpersonal and communication skills

• 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. • 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.