Weekend 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 established criteria. Collaborate with medical directors and other staff to optimize cost-effective care. This remote position requires strong communication, critical thinking, and the ability to work in a fast-paced, dynamic environment. You will contribute to a growing company with significant growth opportunities. Weekend hours are required, with flexible shift options available. A competitive salary and benefits package are offered.

Requirements

• Registered Nurse with active, unencumbered license in the state of residence
• Minimum of 3 years of clinical experience
• Utilization Management experience
• Knowledge of NCQA and CMS standards
• Proficient user of CMS and MCG guidelines
• Proficient in prioritizing work and delegating where indicated
• 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
• Communicate consistently with providers and facility staff to ensure member needs are met
• 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 Milliman care guidelines and Cohere Health’s internal criteria which includes both 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
• Maintain a thorough understanding of accreditation and regulatory requirements, and ensure these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
• Support the Plan's Quality 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

• 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
• 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
• Computer, monitors, keyboard, mouse, and headphones provided