RN Reviewer, United States

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 reputed company prospective review (prior authorization) admission, reputed company, 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 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 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 reputed company a substantive mark in simplifying the way reputed company delivered and contributes to an up and coming company with exponential growth opportunity. What you'll do:

• Review medical necessity for inpatient, reputed company, 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, reputed company, 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 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:

• 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 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, 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 $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 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)
• Subject to change

About reputed company: reputed company’s clinical intelligence platform delivers AI-powered solutions that streamline access to quality care by improving payer-provider collaboration, cost containment, and healthcare economics. reputed company 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 reputed company Suite, anchored by reputed company 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. 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. Healthcare 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, Flare Capital Partners, Longitude Capital, and reputed company Partners, reputed company 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 reputed company, reputed company, caring, and embody our core 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, growth-oriented environment that works for everyone. We can’t wait to learn more about you 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