RN Reviewer
Summary
A registered nurse reviews medical necessity for inpatient, outpatient, and prior authorization cases using clinical guidelines, collaborating with providers and medical directors to ensure cost-effective, high-quality care in a remote healthcare startup.
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.
What you'll do:
- 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
What you'll need:
- Strong communication and collaboration skills across remote teams
- Customer-focused mindset and ability to stay calm under pressure
- Adaptability in a fast-moving, startup environment
- Solid understanding of utilization and case management programs
- Organized, detail-oriented, and comfortable managing multiple priorities
- Knowledge of NCQA/CMS standards; proficiency with MCG (CareWebQI a plus)
Must Haves:
- 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
Important to know about this role:
- This is a 100% remote role, and requires robust internet speeds (above 50 megabytes/second), including the ability to utilize zoom meeting software and to stream video
- The department is staffed seven days per week, 8a m-8pm EST and shifts will be assigned based on need
- Current shift availability is weekend coverage
- This is a full time, 40 hour per week opportunity
Pay & Perks:
💻 Fully remote opportunity with about 5% travel
🩺 Medical, dental, vision, life, disability insurance, and 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
The salary range for this position is $33 per hour to $35 per hour; as part of a total benefits package which includes health insurance, 401k and bonus. In accordance with state applicable laws, Cohere is required to provide a reasonable estimate of the compensation range for this role. Individual pay decisions are ultimately based on a number of factors, including but not limited to qualifications for the role, experience level, skillset, and internal alignment.
Interview Process*:
- Internet Speed Test
- Behavioral Interview(s) with your Hiring Manager!
*Subject to change
About Cohere Health:
Cohere Health’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. Cohere Health works with over 660,000 providers and handles over 12 million prior authorization requests annually. Its responsible AI auto-approves up to 90% of requests for millions of health plan members.
With the acquisition of ZignaAI, we’ve further enhanced our platform by launching our Payment Integrity Suite, anchored by Cohere Validate™, an AI-driven clinical and coding validation solution that operates in near real-time. By unifying pre-service authorization data with post-service claims validation, we’re creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately.
Cohere Health’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022-2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health drives more transparent, streamlined healthcare processes, helping patients receive faster, more appropriate care and higher-quality outcomes.
The Coherenauts, as we call ourselves, 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.
We can’t wait to learn more about you and meet you at Cohere Health!
Equal Opportunity Statement:
Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.
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