Senior UM Nurse Auditor

Summary

The job is a temporary contract position for an experienced Registered Nurse (RN) to audit and validate acute inpatient authorizations, synthesize patterns, and help design automation algorithms at Cohere Health, a fast-growing clinical intelligence company. The role requires 10+ years of experience in conducting payer utilization management clinical reviews or audits for unplanned admissions.

Requirements

• Registered Nurse (RN), associate or bachelor’s degree
• Top performer with 10+ years of experience conducting payer utilization management clinical reviews or audits for acute inpatient authorizations for unplanned admissions
• Deep understanding of payer end-to-end acute inpatient authorization processes, including policies and procedures (e.g., CMS 2 midnight rule, MCG / Interqual guidelines)

Responsibilities

• Audit acute inpatient authorizations for unplanned admissions (including authorization data, clinical records, evidence-based guidelines, and nurse clinical review documentation) to validate the appropriate level of care, with a keen focus on quality
• Synthesize patterns across audits and identify opportunities for clinical review automation
• Help build presentations summarizing audit results for internal and external communication
• Collaborate with cross-functional teams to develop clinical review automation algorithms
• Help evaluate performance of clinical review automation algorithms

Preferred Qualifications

• Independent, objective thinker that doesn’t just take things at face value
• Extremely diligent with an absolute focus on quality
• Adept at analyzing data to help solve problems
• Values simplicity; adept at distilling complex clinical concepts into comprehensive, clear, and actionable frameworks
• Passion for and conceptual understanding of how AI / ML can be used to optimize UM
• Natural inclination to look for ways to improve the status quo
• Proficient in key applications (e.g., clinical review apps, spreadsheets, document processors)