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.

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 …