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All Care To YouCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical necessity reviews, authorization processes, and compliance with CMS and Health Plan guidelines. Proficient in clinical documentation, communication with healthcare stakeholders, and maintaining high-quality standards in a fast-paced environment.
Highest-signal resume keywords
Registered Nurse LicenseClinical ExperienceCM/UM CertificationKnowledge of CMS GuidelinesProficiency in Microsoft Office
About the role
Key responsibilities & impact- Review authorization requests for medical necessity and determine which requests need Medical Director review
- Obtain sufficient medical documentation for informed review
- Process all requests within established time frames
- Document all process steps in the authorization system notes
- Utilize CMS and Health Plan Hierarchy criteria
- Prepare clinical documentation, specific criteria, and record attachments for Medical Director referral
- Conduct retrospective reviews of services to determine medical necessity
- Refer cases to the Medical Director when requests may not meet medical necessity criteria
- Process denials within established timeframes
- Write denial letters meeting CMS and Health Plan requirements
- Apply clinical criteria, guidelines, policies, benefit policies, and clinical judgment to render coverage determinations or recommendations
- Review member utilization and claim history when processing referrals
- Maintain quality reviews while meeting turnaround times for urgent, routine, and retrospective requests
- Maintain an Interrater Reliability Rate of at least 95%
- Meet a daily production standard of 50–90 referrals per day depending on complexity, accuracy, and quality
- Make approval determinations when requests meet appropriateness, medical necessity, and benefit criteria
- Assess, plan, implement, coordinate, monitor, and evaluate healthcare service options
- Act as a clinical resource to all departments
- Communicate with health plans, providers, members, and other parties to facilitate member care treatment plans
- Participate in team training
- Comply with UM policies and procedures and attend provider and interdepartmental calls
- Maintain strict confidentiality when handling sensitive provider and member matters
- Perform other duties as needed
Requirements
What you’ll need- A valid CA and Texas/Multi State Registered Nurse license or Licensed Vocational Nurse
- Current unrestricted CA and Texas/Multi State RN or LVN license
- CM and/or UM training and/or certification
- Knowledge of CM standards, UM standards, Clinical Standards of Care, NCQA requirements, CMS guidelines, Milliman guidelines, and InterQual guidelines
- Knowledge of Medi-Cal, Commercial and Medicare contracts and benefit interpretation preferred
- Five years+ clinical experience
- Two years+ experience in an HMO / IPA / Managed care setting preferred and recommended
- Must be available to work weekends and holidays as business needs require
- Ability to work independently with minimal supervision, exercising judgment and initiative
- Ability to manage multiple tasks with effective prioritization
- Proficiency using Outlook, Microsoft Teams, Zoom, Microsoft Office including Word and Excel, and Adobe
- Detail oriented and highly organized
- Strong ability to multi-task, project management, and work in a fast-paced environment
- Strong problem-solving ability
- Strong self-management and time-management skills
- Ability to work in an extremely confidential environment
- Strong written and verbal communication skills
Benefits
Comp & perks- 100% employer paid medical, vision, dental, and life coverage
- Additional employee paid coverage options
- Paid holidays
- Birthday off
- Unlimited PTO
- 401k plan
- Fully remote work environment
- Flexible work environment and schedules
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity ReviewAuthorization ProcessingClinical Documentation PreparationUtilization Management StandardsBenefit InterpretationRetrospective ReviewDenial Letter WritingHealthcare Service CoordinationQuality Review MaintenanceInterrater Reliability
Soft Skills
Detail OrientedStrong Problem-Solving AbilityTime Management SkillsEffective PrioritizationStrong Written and Verbal Communication
Tools & Technologies
OutlookMicrosoft TeamsZoomMicrosoft OfficeAdobe
Certifications & Qualifications
CM CertificationUM Certification
Industry Keywords
Managed CareHMOIPAClinical Standards of CareNCQA RequirementsMilliman GuidelinesInterQual GuidelinesMedi-CalCommercial ContractsMedicare Contracts