RN Reviewer

Summary

Join Cohere Health as an RN Reviewer and play a crucial role in improving patient care using AI and clinical expertise. You will perform medical necessity reviews, including inpatient, concurrent, and retrospective reviews, ensuring compliance with criteria and medical policies. Collaborate with medical directors and other staff to optimize care and cost-effectiveness. This remote position requires strong clinical experience, utilization management expertise, and excellent communication skills. Cohere Health offers a supportive, growth-oriented environment with opportunities to make a significant impact in healthcare. The company is experiencing rapid growth and offers a competitive compensation package.

Requirements

• Registered Nurse with active, unencumbered license in the state of residence
• Minimum of 3 years of clinical experience
• Utilization Management experience
• Experience working in acute care and/or post-acute care environments
• Knowledge of NCQA and CMS standards and requirements
• Proficient user of MCG guidelines
• Highly organized with excellent time management skills

Responsibilities

• Perform 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
• Consult with Medical Directors when care does not meet applicable criteria or medical policies
• Document clinical information completely, accurately, and in a timely manner
• Meet or exceed production and quality metrics
• Maintain 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
• Identify Clinical Program opportunities and refer members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)
• Collaborate, educate, and consult 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
• Maintain 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
• Support the Plan'sQuality Program: Identify and participate in quality improvement activities as it relates to internal programs, processes studies, and projects
• Perform other duties as assigned

Preferred Qualifications

• HEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience
• Proficiency in using a Mac
• Proficiency in G suite applications
• Demonstrated track record of continuous quality improvement
• Bachelor’s degree in Nursing, Business, or equivalent professional work experience

Benefits

• Health insurance
• 401k
• Bonus
• 100% remote role