Weekend RN Reviewer

Company Overview

Cohere Health is a fast-growing clinical intelligence company that’s improving lives at scale by promoting the best patient-specific care options, using cutting-edge AI combined with deep clinical expertise. In only four years our solutions have been adopted by health plans covering over 15 million lives, while our revenues and company size have quadrupled.  That growth combined with capital raises totaling $106M positions us extremely well for continued success. Our awards include: 2023 and 2024 BuiltIn Best Place to Work; Top 5 LinkedIn™ Startup; TripleTree iAward; multiple KLAS Research Points of Light awards, along with recognition on Fierce Healthcare's Fierce 15 and CB Insights' Digital Health 150 lists.

Opportunity Overview: 

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. You will 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. You will be required to review Commercial, Medicare, and Medicaid lines of business.

You will need to be an agile and comprehensive thinker and planner and be able to work in an environment that is in flux. This position offers the ability to make a substantive mark in simplifying the way healthcare is delivered and contributes to an up and coming company with exponential growth opportunity.

What will you do

• 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.

Your competencies

• 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 envi