Clinical Review & Correspondence Specialist

About the role

The Clinical Review & Correspondence Specialist supports utilization management operations by conducting medical necessity reviews, preparing clear and compliant clinical determinations, and ensuring accurate member and provider communications. This role collaborates with Medical Directors and cross-functional partners to ensure clinical decisions are evidence-based, aligned with regulatory and accreditation standards, and 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

• PT, OT or SLP 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

Qualifications

• 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
• Hightly 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.

Skills

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

Benefits

💻 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

Pay & Perks

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. In accordance with state applicable laws, Cohere 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) with your Hiring Manager!

About Cohere Health

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.

Equal Opportunity Statement

Cohere Health is an Equal Opportunity Employer. We are committed to fostering an environment of mutual respect where equal employment opportunities are available to all. To us, it’s personal.