Clinical Reviewer

Clinical Review & Correspondence RN 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. Through precise clinical review and documentation, you will help support high-quality care, regulatory compliance, and improved member outcomes. What you'll do: 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 What you'll need: 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 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. Bachelor's degree in Nursing 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 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. 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 data with post-service claims validation, we're 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. We've been named to the 2025 Inc. 5000 list and in 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. The Coherenauts, as we call ourselves, who succeed here are empathetic teammates who are candid, kind, caring, and embody our core values and principles. We believe that diverse, inclusive teams make the most impactful work. Cohere is deeply invested in ensuring that we have a supportive, growth-oriented environment that works for everyone. 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. Cohere Health