Clinical Review & Correspondence RN

About the Role

The Clinical Review & Correspondence RN plays a critical role in supporting utilization management operations by conducting medical necessity reviews, preparing clear and compliant clinical determinations, and ensuring accurate member and provider communications. In collaboration with Medical Directors and cross-functional partners, this role ensures that clinical decisions are evidence-based, align with regulatory and accreditation standards, and are communicated effectively and timely.

Responsibilities

• Consult with Medical Directors on clinical determinations, medical necessity decisions, and related clinical correspondence
• Prepare clear, accurate, and compliant member and provider communications in alignment with regulatory and organizational requirements
• Understand regulatory requirements governing utilization management decisions and ensure appropriate application to clinical determinations and communications
• Understand when and why member and provider notifications are required, including regulatory and clinical triggers for written communication
• Support verbal notification workflows when timely communication of clinical determinations is required
• Document clinical information completely, accurately, and in a timely manner
• Consistently meet or exceed productivity, quality, and turnaround time expectations
• Maintain a thorough understanding of accreditation and regulatory requirements and ensure utilization management decision-making and timeliness standards remain in compliance
• Perform other duties as assigned

Requirements

• 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
• Bachelor’s degree in Nursing
• Utilization Review/Utilization Management experience
• Proficiency in using a Mac
• Experienced with G suite applications

Skills

• Thrives in a fast-paced, self-directed environment
• Understands how utilization management and case management programs integrate
• Strong communication skills, able to effectively communicate in a positive and engaging manner and remain calm and professional under pressure
• Comprehensive thinker/planner with understanding of clinical algorithms, care pathways, and how to effectively manage utilization across the care continuum to achieve optimal patient outcomes
• Highly organized with excellent time management skills
• Thrives on continuous process improvement, always actively seeking out practical solutions
• Demonstrated ownership mentality with a willingness to take on new challenges and contribute beyond defined responsibilities when needed

Important Role Details

• This is a 100% remote role, requiring robust internet speeds (above 50 megabytes/second), including the ability to utilize Zoom meeting software and stream video
• The department is staffed seven days per week, 8am–8pm EST, and shifts will be assigned based on need
• This is a full-time, 40-hour-per-week opportunity

Benefits

• Fully remote opportunity with about 5% travel
• Medical, dental, vision, life, and disability insurance, plus 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 plus company holidays
• Up to 14 weeks of paid parental leave
• Pet insurance

Pay

The salary range for this position is $31.00 - $35.00/hour as part of a total benefits package which includes health insurance, 401k, and bonus.

About the Company

Cohere Health’s clinical intelligence platform and agentic AI-powered solutions connect health plans’ strategic goals and providers’ needs, optimizing the speed, cost, and quality of care. With an enterprise approach that streamlines payer-provider decision-making across the care continuum—including policy, prior authorization, payment accuracy, and more—the company improves collaboration and reduces burden, resulting in up to 8x ROI and 94% provider satisfaction.

With the acquisition of ZignaAI, Cohere Health has further enhanced its platform by launching its Payment Integrity Suite, anchored by Cohere 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, Cohere Health is creating a transparent healthcare ecosystem that reduces waste, improves payer-provider collaboration and patient outcomes, and ensures providers are paid promptly and accurately.

Cohere Health’s innovations continue to receive industry-wide recognition, including being named to the 2025 Inc. 5000 list, the Gartner® Hype Cycle™ for U.S. Healthcare Payers (2022–2025), and ranked as a Top 5 LinkedIn™ Startup for 2023 & 2024. Backed by leading investors such as Deerfield Management, Define Ventures, Flare Capital Partners, Longitude Capital, and Polaris Partners, Cohere Health values empathetic teammates who are candid, kind, caring, and embody its core values and principles.