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Role Description

The RN Reviewer position is a crucial role in our organization — in this role you are responsible for performing a full range of activities that will positively impact the organization and contribute to guiding the strategic operations for the company.

As an RN Reviewer, you will:

• Perform prospective review (prior authorization) admission, concurrent, and retrospective reviews according to established criteria and protocols to determine the medical appropriateness of the clinical requests from providers.
• Work closely with Medical Directors and other Cohere Health staff to ensure appropriate cost-effective care by applying your clinical knowledge and critical thinking skills to assess the medical necessity of inpatient admissions, outpatient services and procedures, and provider out of network requests.
• Review Commercial, Medicare, and Medicaid lines of business.
• Be an agile and comprehensive thinker and planner and be able to work in an environment that is in flux.
• Make a substantive mark in simplifying the way healthcare is delivered and contribute to an up and coming company with exponential growth opportunity.

Qualifications

• Strong communication and collaboration skills across remote teams.
• Customer-focused mindset and ability to stay calm under pressure.
• Adaptability in a fast-moving, startup environment.
• Solid understanding of utilization and case management programs.
• Organized, detail-oriented, and comfortable managing multiple priorities.
• Knowledge of NCQA/CMS standards; proficiency with MCG (CareWebQI a plus).

Requirements

• Active, unencumbered RN license (state of residence).
• 3+ years of clinical experience.
• Utilization Management experience.
• Experience in acute or post-acute settings.
• Comfortable using Mac and Google Workspace.
• Strong communication skills and continuous improvement mindset.
• Preferred: HEDIS abstraction, Legal RN, or Utilization Review background.
• Bachelor’s degree in Nursing, Business, or related field.

Benefits

• Fully remote opportunity with about 5% travel.
• Medical, dental, vision, life, disability insurance, and Employee Assistance Program.
• 401K retirement plan with company match; flexible spending and health savings account.
• Up to 184 hours (23 days) of PTO per year + company holidays.
• Up to 14 weeks of paid parental leave.
• Pet insurance.

Important to know about this role

• 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 seven days per week, 8am-8pm EST and shifts will be assigned based on need.
• This is a full time, 40 hour per week opportunity.

Interview Process

• Internet Speed Test.
• Behavioral Interview(s) with your Hiring Manager!