Clinical Review & Correspondence RN

Opportunity Overview: 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