RN Reviewer

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. 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

Review medical necessity for inpatient, concurrent, prior auth, and retrospective cases to ensure appropriate, high-quality care Collaborate with Medical Directors and providers to align on clinical decisions Document reviews accurately and meet production/quality goals Apply MCG, Cohere, and coverage guidelines to ensure compliance and consistency Partner across teams (Operations, Product, Quality, Health Plans) to improve processes and outcomes Identify opportunities for care management or quality improvement programs Support accreditation, regulatory, and quality initiatives