Cohere Health is hiring a
RN Reviewer

Summary

The job is for a Remote RN Reviewer at Cohere Health, a fast-growing clinical intelligence company that improves lives at scale using AI and deep clinical expertise. The role involves performing prospective review (prior authorization) admission, concurrent, and retrospective reviews to determine the medical appropriateness of clinical requests from providers.

Requirements

• Registered Nurse with active, unencumbered license in the state of residence
• Minimum of 3 years of clinical experience
• Utilization Management experience (Required)

Responsibilities

• Performs medical necessity review which includes: inpatient review, concurrent review, prior authorization, retrospective, out of network, treatment setting reviews to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits
• Consults with Medical Directors when care does not meet applicable criteria or medical policies
• Documents clinical information completely, accurately, and in a timely manner
• Meets or exceeds production and quality metrics
• Maintains a thorough understanding of the Cohere Health’s provider and member centric focus, authorization requirements and clinical criteria including MCG care guidelines and Cohere Health’s internal criteria, and National and Local coverage guidelines
• Identifies Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)
• Collaborates, educates, and consults with Providers, Operations, Product, Implementation, Compliance, Quality, and Health Plans to ensure consistent application of clinical criteria as well as promote the CarePath concept to ensure optimal patient outcome
• Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
• Supports the Plan'sQuality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects
• Performs other duties as assigned

Preferred Qualifications

• Experience working in acute care and/or post-acute care environments
• HEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience (Preferred)
• Proficiency in using a Mac
• Proficiency in G suite applications

Benefits

• Salary range for this position is $32.00 to $35.00 hourly; as part of a total benefits package which includes health insurance, 401k and bonus
• This is a 100% remote role, and requires robust internet speeds (above 50 megabytes/second), including the ability to utilize zoom meeting software and to stream video
• The current shift needs are Monday-Friday, 11 AM - 8 PM EST