Remote Clinical Review RN for Utilization Management

Cohere Health; United States; A distancia; USD 4.271.000 - 4.822.000; Jornada completa

Ventajas ofrecidas por este puesto de trabajo

Remote work

401K with company match

Health/dental/vision insurance

Paid time off (PTO)

Descripción de la vacante

Cohere Health is seeking a Clinical Review & Correspondence RN to support utilization management by conducting medical necessity reviews and delivering compliant clinical determinations. You will collaborate with Medical Directors and cross-functional partners to ensure evidence-based decisions aligned with regulatory standards and timely communications.

The role is fully remote with a 40-hour week; requires strong communication, documentation, and a proactive approach to process improvements

Formación

• Active RN license in the state of residence.
• Experience developing member/provider correspondence in a health plan environment.
• Utilization Management experience required.
• Knowledge of NCQA and CMS standards.

Responsabilidades

• Consult with Medical Directors on clinical determinations and related correspondence.
• Prepare clear, accurate member/provider communications.
• Understand regulatory requirements governing utilization management decisions.
• Identify when notifications are required and regulatory triggers for communications.
• Support verbal notification workflows when timely communication is needed.
• Document clinical information completely and timely.
• Meet or exceed productivity, quality, and turnaround time expectations.
• Maintain understanding of accreditation/regulatory requirements and ensure compliance.
• Perform other duties as assigned.

Conocimientos

RN license

Clinical communication

Utilization Management

Regulatory compliance

Time management

Educación

Bachelor’s degree in Nursing

Herramientas

Mac

G Suite

Zoom

Descripción del empleo

Cohere Health is seeking a Clinical Review & Correspondence RN to support utilization management by conducting medical necessity reviews and delivering compliant clinical determinations. You will collaborate with Medical Directors and cross-functional partners to ensure evidence-based decisions aligned with regulatory standards and timely communications.

The role is fully remote with a 40-hour week; requires strong communication, documentation, and a proactive approach to process improvements