Opportunity overview - location: Tampa, Florida/within a 75 mile radius of Tampa, Florida.
Cohere Health is simplifying healthcare for patients, their doctors, and all those who are important in a patient’s healthcare experience. Our focus is to enable an efficient, transparent patient journey where patient goals are central to decision-making.
We are a mission-driven and fast-growing company obsessed with eliminating the wasteful friction patients and doctors experience, particularly for diagnoses that require expensive procedures or medications. To that end, we build products and services that ensure the appropriate plan of care is understood and expeditiously approved, so that patients and doctors can focus on health, rather than payment or administrative hassles.
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 will you do
- Performs medical necessity review which includes: inpatient review, concurrent review, prior authorization, retrospective, out of network, treatment setting reviews to ensure appropriateness and compliance with applicable criteria, medical policy, member eligibility and benefits
- Consults with Medical Directors when care does not meet applicable criteria or medical policies
- Documents clinical information completely, accurately, and in a timely manner
- Meets or exceeds production and quality metrics
- Maintains a thorough understanding of the Cohere Health’s provider and member centric focus, authorization requirements and clinical criteria including Milliman care guidelines and Cohere Health’s internal criteria which includes both National and Local coverage guidelines
- Identifies Clinical Program opportunities and refers members to the appropriate healthcare programs (e.g. case management, disease management, and other health plan programs)
- Collaborates, educates, and consults with Providers, Operations, Product, Implementation, Compliance, Quality, and Health Plans to ensure consistent application of clinical criteria as well as promote the CarePath concept to ensure optimal patient outcome
- Maintains a thorough understanding of accreditation and regulatory requirements, and ensures these requirements are accurately followed and Utilization Management (UM) decision determinations and timeliness standards are within compliance
- Supports the Plan'sQuality Program: Identifies and participates in quality improvement activities as it relates to internal programs, processes studies, and projects
- Performs other duties as assigned.
- Strong customer service skills
- Flexibility and agility, work well in ambiguous situations, clear understanding of an early stage start up environment
- Ability to work cross functionally across remote teams
- Collaborate effectively with multiple stakeholders
- Intellectual curiosity with a strong desire to understand a problem and work it to a viable solution
- Strong communication skills, able to effectively communicate in a positive and engaging manner and able to remain calm and professional under pressure
- Understand how utilization management and case management programs integrate
- Comprehensive thinker/planner with understanding of clinical algorithms, care pathways, and how to effectively manage utilization across the care continuum to achieve optimal patient outcomes
- Ability to work as a team player and assist other members of the UM team where needed
- Thrive in a fast paced, self-directed environment
- Knowledge of NCQA and CMS standards and requirements
- Proficient user of MCG guidelines, Care Web QI user a plus
- Knowledge of AAOS criteria guidelines is a plus
- Proficient in prioritizing work and delegating where indicated
- Highly organized with excellent time management skills
- Registered Nurse with active, unencumbered license in the state of residence
- Minimum of 3 years of clinical experience.
- Utilization Management experience (Required)
- MCG certification (Preferred)
- Experience working in acute care and/or post-acute care environments
- Orthopedic practice experience (Preferred)
- Preferred proficiency in using a Mac
- Preferred proficiency in G suite applications
- Demonstrated track record of continuous quality improvement
- Excellent communication skills both written and oral
- Thrives on continuous process improvement, always actively seeking out practical solutions
- Understanding that this position is very fluid and the term “not my job” doesn’t exist
- Understanding that this job is currently based in the greater Tampa Bay Area (Brandon area) and would require you to be in person often with some work at home opportunity
- Bachelor’s degree (preferred) but not required in the following fields; Nursing, Business, or equivalent professional work experience
We can’t wait to learn more about you and meet you at Cohere Health!