Clinical Review & Correspondence Nurse
Cohere Health · United States
- Hybrid
- Internship
- $83,200 / year
- United States
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Job highlights
- Conduct medical necessity reviews and prepare clinical determinations.
- Ensure accurate and compliant member/provider communications.
- Collaborate with Medical Directors and cross-functional partners.
- Work remotely with robust internet and Zoom capabilities.
- Full-time role with competitive salary and benefits.
About the role
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.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
- 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!
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.
We can’t wait to learn more about you and meet you at Cohere Health!
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.
#BI-Remote
Key skills/competency
- Clinical Review
- Correspondence Nurse
- Utilization Management
- Medical Necessity
- NCQA Standards
- CMS Standards
- Provider Communications
- Member Communications
- Health Plan Experience
- Remote Nursing
Skills & topics
- Clinical Review Nurse
- Utilization Management
- LPN
- Remote Nurse
- Healthcare
- NCQA
- CMS
- Provider Communications
- Medical Necessity
- Health Plan
How to get hired
- Tailor your resume: Highlight your LPN license, 3+ years of clinical experience, and specific Utilization Management background, including NCQA and CMS standards.
- Showcase communication skills: Emphasize your ability to write clear, accurate, and compliant correspondence for members and providers.
- Demonstrate technical aptitude: Mention your proficiency with Mac, G Suite, and strong internet capabilities for remote work.
- Prepare for interviews: Be ready to discuss your thought process for clinical decisions and your experience in fast-paced, self-directed environments.
- Highlight ownership and improvement: Showcase instances where you've taken initiative, improved processes, or contributed beyond your defined role.
Technical preparation
Ensure your internet meets 50+ Mbps speeds for Zoom.,Practice using Mac and G Suite applications.,Familiarize yourself with teleconferencing etiquette.,Review clinical algorithms and care pathways.
Behavioral questions
Describe a time you handled pressure calmly.,How do you ensure accuracy in documentation?,Share an example of process improvement.,How do you manage competing priorities effectively?
Frequently asked questions
- What are the core responsibilities of a Clinical Review Nurse at Cohere Health?
- As a Clinical Review Nurse at Cohere Health, you will be responsible for conducting medical necessity reviews, consulting with Medical Directors on clinical determinations, and preparing clear, accurate, and compliant communications for members and providers. You will also ensure adherence to regulatory and accreditation standards like NCQA and CMS.
- What qualifications are essential for the Clinical Review Nurse role at Cohere Health?
- To be considered for the Clinical Review Nurse position, you must hold an active LPN license, possess at least 3 years of clinical experience, and have specific experience in Utilization Management within a health plan. Knowledge of NCQA and CMS standards is also crucial.
- Is the Clinical Review Nurse position remote, and what are the technical requirements?
- Yes, this is a 100% remote role. It requires robust internet speeds (above 50 megabytes/second) and the ability to effectively use Zoom for meetings and streaming.
- What is the expected work schedule for the Clinical Review Nurse?
- The department operates seven days a week from 8 am to 8 pm EST. Your specific shift will be assigned based on operational needs, and the role is full-time, 40 hours per week.
- What kind of benefits and compensation can I expect as a Clinical Review Nurse at Cohere Health?
- Cohere Health offers a competitive hourly wage between $31.00 and $35.00, along with a comprehensive benefits package that includes medical, dental, vision, life, and disability insurance, a 401K with company match, PTO, paid parental leave, and pet insurance.
- How does Cohere Health utilize AI in its operations, and how might that impact a Clinical Review Nurse?
- Cohere Health leverages AI-powered solutions to optimize care, streamline decision-making, and improve accuracy. While this role focuses on clinical review and communication, understanding the company's innovative approach can provide context for how technology supports clinical operations and enhances patient outcomes.
- What is the interview process like for the Clinical Review Nurse position at Cohere Health?
- The interview process typically includes an internet speed test to ensure remote work capability, followed by behavioral interview(s) with your Hiring Manager. The process is subject to change.
- What does Cohere Health value in its employees, known as 'Coherenauts'?
- Cohere Health seeks empathetic teammates who are candid, kind, caring, and embody their core values. They emphasize diversity, inclusion, and a supportive, growth-oriented environment for all employees.