Senior Inpatient UM Nurse Auditor (CONTRACT)

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 leading edge AI combined with deep clinical expertise. In only four years our solutions have been adopted by health insurance plans covering over 15 million people, 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, along with recognition on Fierce Healthcare's Fierce 15 and CB Insights' Digital Health 150 lists.

Opportunity Overview:

You will play a foundational role in the development of an industry-leading solution that harnesses clinical expertise and AI / ML to enhance acute inpatient utilization management clinical review quality and efficiency. You will apply your clinical expertise to audit acute inpatient authorizations to validate the appropriate level of care, synthesize audit patterns, and help design automation algorithms.

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 you will do:

• Audit acute inpatient authorizations for unplanned admissions (including authorization data, clinical records, evidence-based guidelines, and nurse clinical review documentation) to validate the appropriate level of care, with a keen focus on quality
• Synthesize patterns across audits and identify opportunities for clinical review automation
• Help build presentations summarizing audit results for internal and external communication 
• Collaborate with cross-functional teams to develop clinical review automation algorithms
• Help evaluate performance of clinical review automation algorithms 

Your background & requirements:

• Registered Nurse (RN), associate or bachelor’s degree
• Top performer with 10+ years of experience conducting payer utilization management clinical reviews or audits for acute inpatient authorizations for unplanned admissions
• Deep understanding of payer end-to-end acute inpatient authorization processes, including policies and procedures (e.g., CMS 2 midnight rule, MCG / Interqual guidelines)
• Independent, objective thinker that doesn’t just take things at face value 
• Extremely diligent with an absolute focus on quality
• Adept at analyzing data to help solve problems  
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