Note: The job is a remote job and is open to candidates in USA. Cohere Health is a company focused on optimizing healthcare through clinical intelligence and AI-powered solutions. They are seeking a Clinical Review & Correspondence RN to support utilization management operations by conducting medical necessity reviews and ensuring compliant communication with members and providers.
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
Skills
- 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
- Utilization Review/Utilization Management experience
- Bachelor's degree in Nursing
- 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
Company Overview