Clinical Review & Correspondence Nurse

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

• LPN 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
• Thrive in a fast paced, self-directed environment
• Understand how utilization management and case management programs integrate
• Strong communication skills, able to effectively communicate in a positive and engaging manner and able to 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.
• Nursing Certification
• Utilization Review/Utilization Management experience
• Proficiency in using a Mac
• Experienced with G suite applications
• 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 zoom meeting software and to 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
• 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
• Interview Process*:
• Internet Speed Test
• Behavioral Interview(s) with your Hiring Manager!
• *Subject to change
• About Cohere Health:
• With the acquisition of ZignaAI, we've further enhanced our platform by launching our 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

Benefits

Additional Information

Opportunity Overview: The Clinical Review & Correspondence Nurse 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. Through precise clinical review and documentation, you will help support high-quality care, regulatory compliance, and improved member outcomes.

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