Clinical Review & Correspondence RN

The role

The Clinical Review & Correspondence RN supports utilization management operations by conducting medical necessity reviews and preparing clinical determinations. This role involves collaborating with Medical Directors to ensure decisions are evidence-based and compliant with regulatory standards.

What you will do

• Consult with Medical Directors on clinical determinations and medical necessity decisions
• Prepare compliant member and provider communications
• Apply regulatory requirements to clinical determinations and communications
• Understand regulatory and clinical triggers for written communication
• Support verbal notification workflows
• Document clinical information completely, accurately, and in a timely manner
• Meet productivity, quality, and turnaround time expectations
• Maintain compliance with accreditation and regulatory requirements
• Perform other duties as assigned

Required qualifications

• Registered Nurse with active, unencumbered license in the state of residence
• Experience developing member and provider correspondence within a health plan environment
• Minimum of 3 years of clinical experience
• Utilization Management experience required
• Knowledge of NCQA and CMS standards and requirements
• Ability to thrive in a fast paced, self-directed environment
• Understanding of how utilization management and case management programs integrate
• Strong communication skills
• Understanding of clinical algorithms and care pathways
• Highly organized with excellent time management skills
• Bachelor’s degree in Nursing

Nice to have

• Utilization Review/Utilization Management experience
• Proficiency in using a Mac
• Experienced with G suite applications

Benefits

• 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

Before you apply

• Requires robust internet speeds (above 50 megabytes/second)
• Ability to utilize zoom meeting software and stream video
• Internet Speed Test

About the company

Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs. The company improves collaboration and reduces burden through an enterprise approach that streamlines payer-provider decision-making.