Remote RN Reviewer - Utilization & Care Quality

Cohere Health; Oregon; Hybrid; USD 45,000 - 48,000; Full time

Benefits offered by this job

Fully remote

Medical, dental, vision, life, and EAP

401K with company match

PTO and holidays

Parental leave

Pet insurance

Salary: $33–$35 per hour with benefits

Job summary

Cohere Health seeks an RN Reviewer to perform prior authorization, concurrent, and retrospective reviews to determine medical necessity across commercial, Medicare, and Medicaid lines. You will collaborate with Medical Directors and providers to ensure cost-effective, high-quality care while applying MCG and Cohere guidelines.

This 100% remote, full-time position requires 3+ years of clinical experience, an active RN license, and utilization management expertise.

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 and continuous improvement mindset.
• Preferred: HEDIS abstraction, Legal RN, or Utilization Review background.
• Bachelor's degree in Nursing, Business, or related field.

Responsibilities

• 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.

Skills

Strong communication

Detail-oriented

Adaptability

Time management

Collaboration

Critical thinking

Education

Bachelor's degree in Nursing

Bachelor's degree in Business or related field

Tools

Mac

Google Workspace

MCG guidelines

Job description

Cohere Health seeks an RN Reviewer to perform prior authorization, concurrent, and retrospective reviews to determine medical necessity across commercial, Medicare, and Medicaid lines. You will collaborate with Medical Directors and providers to ensure cost-effective, high-quality care while applying MCG and Cohere guidelines.

This 100% remote, full-time position requires 3+ years of clinical experience, an active RN license, and utilization management expertise.