RN Reviewer

Summary

Join Cohere Health, a rapidly growing clinical intelligence company, as an RN Reviewer and contribute to improving patient care through cutting-edge AI and clinical expertise. In this role, you will perform medical necessity reviews, including inpatient, concurrent, prior authorization, retrospective, and out-of-network reviews, ensuring compliance with established criteria and medical policies. You will collaborate with Medical Directors and other staff to ensure cost-effective care, applying your clinical knowledge and critical thinking skills to assess the medical necessity of various services and procedures. This position offers the opportunity to make a significant impact in simplifying healthcare delivery and joining a company with exponential growth potential.

Requirements

• Strong customer service skills
• Flexibility and agility, work well in ambiguous situations, clear understanding of an early stage start up environment
• Ability to work cross functionally across remote teams
• Collaborate effectively with multiple stakeholders
• Intellectual curiosity with a strong desire to understand a problem and work it to a viable solution
• Strong communication skills, able to effectively communicate in a positive and engaging manner and able to remain calm and professional under pressure
• Understand how utilization management and case management programs integrate
• Comprehensive thinker/planner with understanding of clinical algorithms, care pathways, and how to effectively manage utilization across the care continuum to achieve optimal patient outcomes
• Ability to work as a team player and assist other members of the UM team where needed
• Thrive in a fast paced, self-directed environment
• Knowledge of NCQA and CMS standards and requirements
• Proficient user of MCG guidelines, Care Web QI user a plus
• Highly organized with excellent time management skills
• Registered Nurse with active, unencumbered license in the state of residence
• Minimum of 3 years of clinical experience
• Utilization Management experience (Required)
• Experience working in acute care and/or post-acute care environments
• 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 department is staffed Monday-Friday 8am-8pm EST and shifts will be assigned based on need

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

• HEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience (Preferred)
• Preferred proficiency in using a Mac
• Preferred proficiency in G suite applications
• Demonstrated track record of continuous quality improvement
• Excellent communication skills both written and oral
• Thrives on continuous process improvement, always actively seeking out practical solutions
• Understanding that this position is very fluid and the term “not my job” doesn’t exist
• Bachelor’s degree (preferred) but not required in the following fields; Nursing, Business, or equivalent professional work experience

Benefits

• Health insurance
• 401k
• Bonus