Weekend RN Reviewer

Summary

Join Cohere Health as an RN Reviewer and perform a full range of activities impacting the organization's strategic operations. You will conduct prospective, concurrent, and retrospective medical necessity reviews to ensure appropriate and cost-effective care. Collaborate with Medical Directors and staff to assess medical necessity for various services and provider requests across different lines of business. This role requires strong clinical knowledge, critical thinking, and adaptability in a dynamic environment. You will contribute to simplifying healthcare delivery and work in a rapidly growing company. This is a 100% remote position requiring weekend hours and robust internet speed.

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
• Willingness to communicate verbally and in writing with providers and facility staff
• 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
• Proficient user of CMS and MCG guidelines, Care Web QI user a plus
• Proficient in prioritizing work and delegating where indicated
• 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
• 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
• Weekend hours are required. Will entertain 3 x 12 or 4 x 10 hrs shifts (Fri/Sat/Sun +1 other day of the week) or Sat/Sun/Mon (+1 other day of the week)

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
• Communicate consistently with providers and facility staff to ensure member needs are met
• 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 Milliman care guidelines and Cohere Health’s internal criteria which includes both 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
• 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's Quality 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

• MCG certification
• Experience working in acute care and/or post-acute care environments
• Orthopedic practice experience
• HEDIS RN/abstraction, Legal RN, Utilization Review/Utilization Management experience
• 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

• Computer, monitors, keyboard, mouse, and headphones provided
• Health insurance
• 401k
• Bonus