RN Reviewer

The role

You will perform prospective, concurrent, and retrospective reviews to determine medical necessity for clinical requests. You will collaborate with Medical Directors and staff to ensure cost-effective care across Commercial, Medicare, and Medicaid lines of business.

What you will do

• Review medical necessity for inpatient, concurrent, prior auth, and retrospective cases
• 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 to improve processes and outcomes
• Identify opportunities for care management or quality improvement programs
• Support accreditation, regulatory, and quality initiatives

Required qualifications

• Active, unencumbered RN license (state of residence)
• 3+ years of clinical experience
• Utilization Management experience
• Experience in acute or post-acute settings
• Comfortable using Mac and Google Workspace
• Strong communication skills
• Continuous improvement mindset
• Knowledge of NCQA/CMS standards
• Robust internet speeds (above 50 megabytes/second)
• Ability to utilize zoom meeting software and stream video

Nice to have

• Proficiency with MCG (CareWebQI a plus)
• HEDIS abstraction
• Legal RN
• Utilization Review background

Benefits

• Medical, dental, vision, life, disability insurance
• Employee Assistance Program
• 401K retirement plan with company match
• Flexible spending and health savings account
• Up to 184 hours (23 days) of PTO per year
• Company holidays
• Up to 14 weeks of paid parental leave
• Pet insurance

Before you apply

• Internet Speed Test
• Behavioral Interview(s) with your Hiring Manager

About the company

Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care. The company works with over 660,000 providers and handles over 12 million prior authorization requests annually.