Utilization Management Physician Reviewer

Opportunity Overview: We are looking for physicians who have expertise in Internal Medicine including medical and surgical clinical areas to deliver on Cohere’s program by determining the medical appropriateness of services by reviewing clinical information and applying evidence-based guidelines. Reporting to the Managing Medical Director 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. This is a remote-first role that may require travel to Boston, MA for new hire onboarding and occasional in-person team meetings and company events. What you’ll do: Support the clinical content team in reviewing the company’s clinical decision guidelines and evidence based literature Provide expert input on content for influencing physicians in medical 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 and knowledge of evidence based literature and medical society guidelines 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 medical necessity 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 specifi

Become a part of our caring community The Utilization Management Registered Nurse uses clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. You will report to the Manager of Utilization Management and serve as a member of the One Home/Home Solutions Utilization Management team. This team manages post-acute care services. These services include Skilled Nursing Facility (SNF), Home Health, and Durable Medical Equipment (DME). The team's goal is to ensure members receive the appropriate level of care in the most appropriate setting. As a Utilization Management Registered Nurse: You will use clinical nursing skills to interpret and support the coordination, documentation and communication of medical services and benefit administration determinations. Using established medical criteria, you will make determinations based on information provided by the attending physician and other care providers You will complete request determinations within established processing time frames. (i.e. 10 reviews per day?) You will communicate with providers, members, or other parties to facilitate care and treatment. You will help deliver coordinated care for our members You will understand department, segment, and organizational strategy and operating goals, including their linkages to related areas. Use your skills to make an impact Required Qualifications: Must hold Compact Registered Nurse (RN) license in your state of residence Greater than one year of clinical experience as a RN in a hospital, SNF, Home Health, or acute care setting. Must be passionate about contributing to an organization focused on improving consumer experiences Preferr

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

firsthand supports individuals living with SMI (serious mental illness). Our holistic approach includes a team of peer recovery specialists, benefits specialists and clinicians. Our teams focus on meeting each individual where they are and walking with them side by side as a trusted guide and partner on their journey to better health. firsthand's team members use their lived experience to build trust with these individuals and support them in reconnecting to the healthcare they need, while minimizing inappropriate healthcare utilization. Together with our health plan partners, we are changing the way our society supports those most impacted by SMI. We are cultivating a team of deeply passionate problem-solvers to tackle significant and complex healthcare challenges with us. This is more than a job—it's a calling. Every day, you will engage in work that resonates with purpose, gain wisdom from motivated colleagues, and thrive in an environment that celebrates continuous learning, creativity, and fun. The Consultation-Liaison Psychiatric Nurse Practitioner is a board-certified Psychiatric Mental Health Nurse Practitioner who serves as the founding clinician of firsthand's hospital psychiatric consult service, and as the most visible representative of firsthand inside our partner hospital. When an emergency physician or hospitalist places a psychiatric consult, you are the person who shows up the same day, performs the assessment at the bedside, and begins treatment in the room: medication management, long-acting injectable antipsychotics, medication for addiction treatment where indicated, and substantive therapeutic work — not a chart review and a medication reconciliation. You follow admitted patients to the floor, document in the hospital's EHR, and become known to the hospital teams by name. You practice alongside a consultation-liaison psychiatrist who provides supervision and escalation support for complex management; the two of you are intr

firsthand supports individuals living with SMI (serious mental illness). Our holistic approach includes a team of peer recovery specialists, benefits specialists and clinicians. Our teams focus on meeting each individual where they are and walking with them side by side as a trusted guide and partner on their journey to better health. firsthand's team members use their lived experience to build trust with these individuals and support them in reconnecting to the healthcare they need, while minimizing inappropriate healthcare utilization. Together with our health plan partners, we are changing the way our society supports those most impacted by SMI. We are cultivating a team of deeply passionate problem-solvers to tackle significant and complex healthcare challenges with us. This is more than a job—it's a calling. Every day, you will engage in work that resonates with purpose, gain wisdom from motivated colleagues, and thrive in an environment that celebrates continuous learning, creativity, and fun. The Consultation-Liaison Psychiatric Nurse Practitioner is a board-certified Psychiatric Mental Health Nurse Practitioner who serves as the founding clinician of firsthand's hospital psychiatric consult service, and as the most visible representative of firsthand inside our partner hospital. When an emergency physician or hospitalist places a psychiatric consult, you are the person who shows up the same day, performs the assessment at the bedside, and begins treatment in the room: medication management, long-acting injectable antipsychotics, medication for addiction treatment where indicated, and substantive therapeutic work — not a chart review and a medication reconciliation. You follow admitted patients to the floor, document in the hospital's EHR, and become known to the hospital teams by name. You practice alongside a consultation-liaison psychiatrist who provides supervision and escalation support for complex management; the two of you are intr

What you will be doing: As a Service Line Advisor, you will serve as part of the GHX Value Analysis Advisory Services Team, where you will pair your subject-matter expertise with evidence to formulate and deliver actionable recommendations for medical device use in health systems. You will bring, and develop, a comprehensive perspective on cardiovascular, interventional radiology (IR), and general surgery device spend and utilization trends and combine this with GHX Value Analysis's clinical expertise to advise health system leadership and physicians on opportunities to reduce unwarranted variation and unnecessary device costs and improve patient outcomes. The successful candidate will have deep expertise in cardiovascular, interventional radiology, and general surgery device use, strategic sourcing strategy and the US vendor landscape, share a passion for learning and understanding medical device technology, and be excited to use evidence-based solutions to transform healthcare. Additionally, a successful candidate will be a collaborative, energetic problem solver with a successful track record of leading medical device utilization and cost-reduction projects, with a focus on driving both business impact and stakeholder satisfaction. Responsibilities include: Be the go-to expert in health system Cardiovascular, Interventional Radiology, and General Surgery device sourcing strategy (e.g., cardiac rhythm management, coronary/peripheral interventional devices, embolization and vascular access devices, energy/vessel-sealing devices, surgical mesh, etc.); apply medical device industry expertise to proactively build a knowledge base of market trends, best practice product selection and utilization, vendor landscape, and reimbursement Become a trusted advisor Analyze and interpret clinical and financial data to inform value-based device spend decisions Maintain up-to-date knowledge of GHX Value Analysis's research, evidence insights and recommendations, as well as market