Remote Clinical Review RN – Utilization Management

Cohere Health; Oregon; Hybrid; USD 43,000 - 48,000; Full time

Benefits offered by this job

Remote work

Health insurance

401k plan

PTO

Parental leave

Pet insurance

Job summary

Cohere Health is hiring a Clinical Review & Correspondence RN to support utilization management by reviewing medical necessity and crafting compliant determinations for members and providers.

You will collaborate with Medical Directors and cross-functional teams to ensure evidence-based decisions, clear communications, and timely updates. This role requires RN licensure, 3+ years of clinical experience, and UM knowledge. Fully remote with strong internet and EST hours.

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.
• Proficiency in using a Mac and G Suite applications.

Responsibilities

• Consult with Medical Directors on clinical determinations and related correspondence.
• Prepare clear, compliant member and provider communications.
• Understand regulatory requirements governing utilization management decisions.
• Know when and why notifications are required, including regulatory triggers.
• 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 accreditation and regulatory compliance in utilization decisions.

Skills

Regulatory knowledge

Communication skills

Time management

Organizational skills

Ownership mindset

Utilization Management

Education

Bachelor's degree in Nursing

Tools

Mac

G Suite

Job description

Cohere Health is hiring a Clinical Review & Correspondence RN to support utilization management by reviewing medical necessity and crafting compliant determinations for members and providers.

You will collaborate with Medical Directors and cross-functional teams to ensure evidence-based decisions, clear communications, and timely updates. This role requires RN licensure, 3+ years of clinical experience, and UM knowledge. Fully remote with strong internet and EST hours.