Clinical Review & Correspondence RN

Become a part of our caring community The Care Management Support Assistant contributes to administration of care management. Provides non-clinical support to the assessment and evaluation of members' needs and requirements to achieve and/or maintain optimal wellness state by guiding members/families toward and facilitate interaction with resources appropriate for the care and wellbeing of members. The Care Management Support Assistant performs basic administrative/clerical/operational/customer support/computational tasks. Typically works on routine and patterned assignments. The Care Management Support Assistant will review inbound referrals and correspondence for processing, fulfilment or resolution utilizing all appropriate software systems and resources. Screen physician’s orders and documentation to identify that all qualifying medical documentation and required information is included. When necessary, request additional applicable information from referring entity. Perform verification of benefits coverage and eligibility for services per Health Plan contract. Review referral data matching it against specified medical terms and diagnoses or procedure codes and follow established procedures for approving request or referring request for further review. Provide referral management education to members and providers regarding medical benefits, referral status and prior authorizations. Communicate with patient to confirm demographics and explain the details of the services/care requested. Coordinate the timely delivery of care and services with providers. Also communicate with referring entities, providers, and members regarding final referral determination while maintaining detailed documentation to record patient, physician, referral source and provider interactions and communications. Work with Pre-Authorization, Utilization Management, Billing, Pharmacy, and Home Care r

Opportunity Overview: We are looking for physicians who have expertise in Orthopedic Spine Surgery to deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Managing Medical Director, MSK Spine and Ortho for Cohere Health, and part of the review team that includes non-clinical intake specialists and nurses, this is a critical role in a Series B company that is rapidly scaling to impact millions of patients. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. What you’ll do: Provide timely medical reviews that meet Cohere’s stringent quality parameters Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision Use correct templates for documenting decisions during case review Meet the appropriate turn-around times for clinical reviews Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers Support projects specific to building the team's clinical expertise and efficiency, as delegated Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated What you’ll need: Completed US-based residency program in Orthopedic or Neurosurgery Surgery and fellowship program in Spine Surgery Board cer

We are looking for physicians who have expertise in Orthopedic Surgery to deliver on Cohere’s musculoskeletal and orthopedic programs by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Managing Medical Director, Orthopedic Surgery for Cohere Health, and part of the review team that includes non-clinical intake specialists and nurses, this is a critical role in a company that is rapidly scaling to impact millions of patients. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. What you’ll do: Provide timely medical reviews that meet Cohere’s stringent quality parameters Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision Use correct templates for documenting decisions during case review Meet the appropriate turn-around times for clinical reviews Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers Support projects specific to building the team's clinical expertise and efficiency, as delegated Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated What you’ll need: Completed US-based residency program in Orthopedic Surgery Board certification by appropriate specialty board as an MD or DO with a current unrestricted sta

Opportunity Overview: We are looking for physicians who have expertise in Cardiology and Vascular medical topics to deliver on Cohere’s Cardiology program by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Managing Medical Director, Cardiovascular for Cohere Health, this is a critical role in a company that is rapidly scaling to impact millions of patients. This is a fast-paced environment that favors people who are able to learn quickly, be hands-on, handle ambiguity, and communicate effectively with people of different backgrounds and perspectives. What you’ll do: Support the clinical development team in reviewing the company’s clinical decision guidelines and evidence based literature Provide expert input on content and programs for influencing physicians in cardiovascular care to improve the quality of patient outcomes Provide timely medical reviews that meet Cohere’s stringent quality and timeliness parameters Provide clinical determinations based on evidence-based criteria while utilizing clinical acumen Clearly and accurately document all communication and decision-making in Cohere workflow tools, ensuring a member and provider can easily reference and understand your decision Use correct templates for documenting decisions during case review Conduct timely peer-to-peer discussions with treating providers to clarify clinical information and to explain review outcome decisions, including feedback on alternate treatment based on medical necessity criteria and evidence-based research Demonstrate the highest level of professionalism, accountability, and service in your interactions with Cohere teammates and providers Support projects specific to building the team's clinical expertise and efficiency, as delegated Support the team on operational improvements and member/provider experience involving clinical review tasks, as delegated What you’ll need U.S.-based resi

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Remote | Work from Home | Eastern Time Zone Preferred Are you an experienced RN looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care at the right time through evidence-based clinical review, care coordination, and healthcare advocacy. What You'll Do Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care Collaborate with providers and care teams to facilitate appropriate treatment and care planning Identify opportunities to improve quality of care, member outcomes, and healthcare utilization Connect members with additional programs and resources that support their healthcare needs Serve as a clinical resource for internal and external stakeholders WHAT YOU BRING - REQUIRED Active, unrestricted RN license in your state of residence 2+ years of adult acute care and/or critical care nursing experience Strong clinical assessment, critical thinking, and decision-making skills Excellent verbal and written communication skills Ability to multitask and

We’re building a world of health around every individual — shaping a more connected, convenient and compassionate health experience. At CVS Health®, you’ll be surrounded by passionate colleagues who care deeply, innovate with purpose, hold ourselves accountable and prioritize safety and quality in everything we do. Join us and be part of something bigger – helping to simplify health care one person, one family and one community at a time. Registered Nurse (RN) – Utilization Management Remote | Work from Home | Eastern Time Zone Preferred Are you an experienced RN looking to leverage your clinical expertise in a non-bedside role? Join our Utilization Management team and help ensure members receive the right care at the right time through evidence-based clinical review, care coordination, and healthcare advocacy. What You'll Do Review clinical information and apply established guidelines, policies, and clinical judgment to support coverage determinations Assess, coordinate, monitor, and evaluate healthcare services and benefits across the continuum of care Collaborate with providers and care teams to facilitate appropriate treatment and care planning Identify opportunities to improve quality of care, member outcomes, and healthcare utilization Connect members with additional programs and resources that support their healthcare needs Serve as a clinical resource for internal and external stakeholders WHAT YOU BRING - REQUIRED Active, unrestricted RN license in your state of residence 2+ years of adult acute care and/or critical care nursing experience Strong clinical assessment, critical thinking, and decision-making skills Excellent verbal and written communication skills Ability to multitask and