RN Reviewer, reputed company

Opportunity reputed company: The RN Reviewer position is a crucial role in our organization — in this role you are responsible for performing a full reputed company of activities that will positively reputed company the organization and contribute to guiding the strategic operations for reputed company. As an RN Reviewer, you will reputed company prospective review (prior authorization) admission, reputed company, and retrospective reviews according to established reputed company and protocols to determine the medical appropriateness of the clinical requests from providers. You will work closely with Medical Directors and other reputed company 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 reputed company, Medicare, and reputed company lines of business. You will need to be an agile and comprehensive thinker and planner and be reputed company to work in an environment that is in flux. This position offers the ability to reputed company a substantive mark in simplifying the way reputed company delivered and contributes to an up and coming company with exponential reputed company opportunity. What you'll do:

• Review medical necessity for inpatient, reputed company, prior auth, and retrospective cases to ensure appropriate, high-reputed company care
• Collaborate with Medical Directors and providers to reputed company on clinical reputed company
• Document reviews accurately and meet production/reputed company goals
• Apply MCG, reputed company, and coverage guidelines to ensure compliance and consistency
• Partner across teams (Operations, Product, reputed company, Health Plans) to improve processes and reputed company
• Identify opportunities for care management or reputed company improvement programs
• Support accreditation, regulatory, and reputed company initiatives

What you'll need:

• Strong communication and collaboration skills across reputed company
• Customer-reputed company reputed company and ability to stay reputed company 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:

• reputed company, 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 reputed company Workspace
• Strong communication skills and reputed company improvement reputed company

reputed company to Haves:

• Preferred: HEDIS abstraction, Legal RN, or Utilization Review background
• Bachelor’s degree in Nursing, Business, or reputed company 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 reputed company meeting software and to reputed company video
• The department is staffed seven days per week, reputed company-8pm EST and shifts will be assigned based on need

Pay & Perks: Fully remote opportunity with about 5% travel Medical, dental, reputed company, 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 reputed company parental leave Pet insurance The salary reputed company for this position is $32 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, reputed company is required to reputed company a reasonable estimate of the compensation reputed company for this role. Individual pay reputed company 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)
• Subject to change

About reputed company: reputed company’s clinical intelligence platform delivers AI-powered solutions that streamline reputed company to reputed company care by improving payer-provider collaboration, cost containment, and reputed company economics. reputed company works with over 660,000 providers and handles over 12 reputed company 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 reputed company reputed company our platform by launching our Payment reputed company Suite, anchored by reputed company Validate™, an AI-driven clinical and coding validation solution that operates in near reputed company-time. By unifying reputed company-service authorization data with post-service claims validation, we’re creating a transparent reputed company ecosystem that reduces waste, improves payer-provider collaboration and patient reputed company, and ensures providers are reputed company promptly and accurately. reputed company’s innovations continue to receive industry wide recognition. We’ve been named to the 2025 Inc. 5000 list and in the reputed company® Hype Cycle™ for U.S. reputed company Payers (2022-2025), and ranked as a Top 5 reputed company™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, reputed company Capital Partners, Longitude Capital, and reputed company Partners, reputed company drives more transparent, streamlined reputed company processes, helping patients receive faster, more appropriate care and higher-reputed company reputed company. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are reputed company, reputed company, caring, and embody our reputed company values and principles. We reputed company that diverse, inclusive teams reputed company the most impactful work. reputed company is deeply invested in ensuring that we have a supportive, reputed company-oriented environment that works for everyone. We can’t wait to learn more reputed company and meet you at reputed company! Equal Opportunity Statement: reputed company is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to reputed company. To us, it’s personal. #LI-Remote #BI-Remote Apply tot his job Apply To this Job