Associate Director, Clinical Rules Management

Your Future Evolves Here

Seeking a detail-oriented Clinical Rules Management, Associate Director who will play a critical role in ensuring the accuracy and integrity of our clinical rule engine, impacting our clinical review and recommendations for thousands of patients every day. This role will be responsible for the design, implementation, support, and maintenance of our clinical rules management systems. The ideal candidate will have a strong understanding of healthcare data and systems, with the ability to analyze and interpret complex clinical pathways to improve patient care.

What You Will Be Doing:

• Collaborate with clinical staff to develop and implement systems that improve patient outcomes and enable efficient use of resources.

• Use exiting reports or help design new reports to help the team with identifying trends and design solution and prioritize implementations.

• Assist with troubleshooting and problem resolution within the clinical information systems.

• Conduct regular system audits to ensure the accuracy and quality of data.

• Lead the evaluation of clinical processes in collaboration with other clinical corporate, division, and facility teams to facilitate process redesign and guide application of technology to ensure adoption, satisfaction, and compliance with policies and reporting requirements.  

• Proactively monitor updates to ICD-10/CPT/HCPCS codes, notify stakeholders of any changes, and ensure the system is updated on a timely basis, along with identifying its impact on clinical rules and implementing changes.

• Support new client implementations.

• Improve existing rule triggers for all specialties, including RBM, Physical Medicine, Genetic Testing, Pain Medicine, Sleep Study, Radiation Oncology, Cardiology, and any new specialty taken on by the organization.

• Development and delivery of application training to end clients.

Qualifications Required & Preferred:

• Bachelor’s degree plus a minimum of 7-10 years’ relevant work experience

• Experience in managing small-mid size teams

• Ability to use reports and draw conclusions on where immediate improvements can be made to resolve issues

• Good understanding of specialty benefit management business

• Ability to comprehend what a front-end user may/may not be able to answer during auth process

• Conduct working sessions with the doctors and ask intelligent questions to limit the number of questions asked during auth process

• Project management skills to keep up with multiple time sensitive tasks and projects

• Proficiency with Microsoft Office Suite (Word, Excel, Visio, PowerPoint, SharePoint, Teams)

• Team player, critical thinker with excellent interpersonal skills

• Knowledge of ICD-10-CM and CPT coding assignments for billing in an outpatient or physician office setting

• Understanding of various lines of businesses in healthcare industry Medicare, Medicaid, Commercial and Exchange plans

• Strong adaptability and capacity to work in fast-paced environments

• Effective written and verbal communication skills

Preferred:

• Understanding of complex billing requirements in Radiation Oncology/Oncology/Cardiology/Radiology/ setting

• Familiarity with CaseLogix or any clinical rules management system

• Logical skills and familiarity with MS-Visio and convert them to an excel format for building the Q&A in the system.

• Clinical knowledge or previous experience in a medical environment is a big plus

• Prior experience with working in some type of rules engine or prior authorization provider portals

Technical Requirements:

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 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. If you need reasonable accommodation to access the information provided on this website, please contact recruiting@evolent.com for further assistance.