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Your Future Evolves Here

Evolent partners with health plans and providers to achieve better outcomes for people with most complex and costly health conditions. Working across specialties and primary care, we seek to connect the pieces of fragmented health care system and ensure people get the same level of care and compassion we would want for our loved ones.

Evolent employees enjoy work/life balance, the flexibility to suit their work to their lives, and autonomy they need to get things done. We believe that people do their best work when they're supported to live their best lives, and when they feel welcome to bring their whole selves to work. That's one reason why diversity and inclusion are core to our business.

Join Evolent for the mission. Stay for the culture.

What You’ll Be Doing:

Job Summary:

The Senior Director, Scope Management leads a small team of analysts and oversees the end-to-end management of prior authorization and financial scope at for Evolent Specialty Services. The Senior Director role will act the data steward, maintaining the source of truth for specialty UM agreements, facilitating scope related decisions, and ensure alignment across all systems of record.

Essential Functions:

• Owns end-to-end specialty scope management process and is responsible for ensuring scope decisioning and codification is completed and downstream processes that consume PA and financial code scope are provided accurate input data

• Accountable for accurate and timely decisioning on PA and financial code scope implementations and changes

• Develop and implement operational and technical strategy to identify, facilitate, coordinate, and synthesize various business, client, contract, state regulatory, and other third-party (e.g., HCPCS, CPT changes) inputs into accurate specialty standard and client-level prior authorization and financial scope requirements.

• Lead team of analysts to capture and curate scope configuration source-of-truth, supporting current configurations, change history, and rationale.

• Facilitate and track the communication of scope configuration to downstream application and payment systems and upstream to implementation teams.

• Contribute to the development, implementation, and execution of processes to efficiently support scope related issues and inquiries from client-facing and internal business and technical teams.

• Act as end-to-end subject matter expert for assigned scope providing input into business decisions, process changes, and technical platform changes.

• Leverage subject matter expertise to support prior authorization and financial scope reconciliations.

• Accountable for on-going surveillance of coding publications provided by American Medical Association (AMA), Center of Medicare and Medicaid services (CMS), Food and Drug Administration (FDA) and various prior authorization lists to facilitate prompt decisioning by clinical and business review teams and the propagation of code updates across all EVH systems.

• Responsible for the identification of new therapies, changes in coding landscape, and client requests that could have an impact on the overall financial performance of risk business and ensuring issues are brought to executive decisioning forum.

• Ability to communicate across a wide range of audiences to inform, persuade, and facilitate consensus.

• Ability to use critical thinking skills to develop processes and solutions in dynamic and complex contexts.

• Ability to balance competing stakeholder priorities.

• Strong analytical abilities, with track record of identifying insights from quantitative and qualitative data.

• Manage a small team of analysts.

Required Qualifications:

• Bachelor’s degree, preferably with a healthcare focus (health administration, epidemiology, public health, biology) or a quantitative major (such as healthcare informatics or nursing informatics).

• 10+ years of professional experience in value-based healthcare analytics or utilization management with a payer, provider, clinical vendor, managed care, or related healthcare consulting entity

• 10+ years’ experience and understanding of medical billing and coding functions, including HCPCS, CPT, and ICD-10.

• 5+ years direct experience managing teams.

• 5+ years experience managing or analyzing large data sets.

• Ability to work independently with limited oversight.

• Advanced skills in Microsoft Excel

• Proficiency in PowerPoint

• Proficiency in SQL or Python

Preferred Qualifications:

• Master's Degree, especially with a healthcare or quantitative focus (health administration, epidemiology, public health, biology, informatics)

• Active clinical credential (RN, BSN, LPN, etc.)

• 5+ years of healthcare economics experience

• Experience with BI tools or coding (e.g., Power BI)

• Active credential or coding certification:

• Registered Health Information Technician (RHIT)

• Certified Hematology and Oncology Coder (CHONC)

• Certified Coding Associate (CCA)

• Certified Professional Coder (CPC)

• Certified Coding Specialist (CCS)

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.

The expected base salary/wage range for this position is $150,000-155,000. This position is also eligible for a bonus component that would be dependent on pre-defined performance factors. As part of our total compensation package, Evolent is proud to offer comprehensive benefits (including health insurance benefits) to qualifying employees. All compensation determinations are based on the skills and experience required for the position and commensurate with experience of selected individuals, which may vary above and below the stated amounts.

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