Remote RN Utilization Review Specialist

Cohere Health; United States; À distance; USD 45 000 - 48 000; Plein temps

Avantages offerts par ce poste

Fully remote

Medical insurance

Dental coverage

Vision coverage

Life insurance

Disability insurance

401K with match

FSA/HSA

PTO 23 days

Parental leave

Pet insurance

Résumé du poste

Cohere Health seeks an experienced RN Reviewer to perform prospective, concurrent, and retrospective reviews ensuring medical necessity and high-quality care. You will collaborate with Medical Directors, providers, and cross-functional teams to apply MCG and Cohere guidelines, supporting cost-effective care for Commercial, Medicare, and Medicaid lines.

The role is fully remote, requires strong communication, and entails 40 hours per week with flexible scheduling.

Qualifications

• Active, unencumbered RN license (state of residence).
• 3+ years of clinical experience.
• Utilization Management experience.
• Experience in acute or post-acute settings.

Responsabilités

• 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.
• Partner across teams to improve processes and outcomes.
• Identify opportunities for care management or quality improvement programs.
• Support accreditation, regulatory, and quality initiatives.

Connaissances

RN license

3+ years

Utilization management

Acute/post-acute

Mac & Google Workspace

HEDIS experience

Formation

Bachelor's degree in Nursing

Outils

CareWebQI

Description du poste

Cohere Health seeks an experienced RN Reviewer to perform prospective, concurrent, and retrospective reviews ensuring medical necessity and high-quality care. You will collaborate with Medical Directors, providers, and cross-functional teams to apply MCG and Cohere guidelines, supporting cost-effective care for Commercial, Medicare, and Medicaid lines.

The role is fully remote, requires strong communication, and entails 40 hours per week with flexible scheduling.