RN Reviewer

Company Overview

Cohere Health is illuminating healthcare for patients, their doctors, and all those who are important in a patient’s healthcare experience, both in and out of the doctors office.  Founded in August, 2019, we are obsessed with eliminating wasteful friction patients and doctors experience in areas that have nothing to do with health and treatment, particularly for diagnoses that require expensive procedures or medications.  To that end, we build software that is expressly designed to ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles.

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.

Last but not least: People who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone.

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
• 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 MCG care guidelines and Cohere Health’s internal criteria, and 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 as well as promote the CarePath concept to ensure optimal patient outcome
• 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'sQuality 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
• 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 m