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Devoted HealthCore Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Clinical Review Audits and Utilization Management processes, ensuring compliance with CMS and regulatory standards. Proficient in analyzing clinical documentation, identifying trends, and translating findings into actionable recommendations for quality improvement.
Highest-signal resume keywords
Registered Nurse (RN) LicenseClinical Audit ExperienceUtilization Management KnowledgeAnalytical SkillsClinical Documentation Review
About the role
Key responsibilities & impact- Conduct ongoing Clinical Review audits and monitoring activities for the assigned UM team
- Review clinical determinations, documentation, application of clinical criteria, and adherence to established UM processes
- Ensure audits align with CMS, regulatory, contractual, and organizational requirements
- Maintain audit schedules, sampling requirements, documentation, and monthly audit-cycle deadlines
- Analyze audit results to identify trends, root causes, recurring variances, and process improvement opportunities
- Translate findings into actionable recommendations for UM leadership
- Identify opportunities for staff education, re-education, workflow improvement, and process standardization
- Support new-hire on-the-job training, ongoing staff education, and targeted re-education
- Partner with leaders to develop and implement corrective actions, validate them, and monitor post-education results
- Support development, maintenance, and enhancement of clinical audit tools and methodologies
- Support delegation oversight auditing and monitoring for applicable UM First Tier, Downstream, and Related Entities
- Support readiness activities for internal, external, CMS, and regulatory audits
- Maintain accurate audit documentation and compliance evidence
- Partner with UM leadership, Medical Directors, UM Operations, Compliance, Quality, Claims, Provider Services, and other stakeholders as a clinical subject matter expert
- Participate in process improvement initiatives supporting quality, compliance, efficiency, and member/provider experience
- Escalate significant clinical, compliance, or regulatory concerns through established channels
Requirements
What you’ll need- Active, unrestricted Registered Nurse (RN) license or Licensed Vocational/ Practical Nurse (LVN/LPN)
- Clinical nursing experience, preferably within Utilization Management, Clinical Review, Quality, Audit, or a related healthcare environment
- Experience reviewing clinical documentation and applying clinical criteria to healthcare services
- Knowledge of Medicare Advantage Utilization Management processes and applicable CMS requirements
- Experience conducting clinical audits, quality reviews, or monitoring activities
- Strong understanding of clinical documentation and medical necessity principles
- Strong analytical, organizational, communication, and attention-to-detail skills
- Ability to identify trends, assess root causes, and translate findings into actionable recommendations
- Ability to work independently while collaborating with cross-functional teams and managing multiple audit and training deadlines
- Desired: Experience with CMS, Medicare Advantage, regulatory audits, compliance monitoring, delegation oversight/FDR monitoring, clinical audit tools, clinical education or new-hire OJT, quality improvement, corrective action, or performance improvement initiatives
- Desired: Familiarity with UM clinical criteria, including InterQual or similar evidence-based criteria
- Desired: Experience using data and audit results to identify trends and drive operational improvement
- Desired: Experience with technology-enabled or AI-supported clinical review and audit processes
Benefits
Comp & perks- Employer sponsored health, dental and vision plan with low or no premium
- Generous paid time off
- $100 monthly mobile or internet stipend
- Stock options for all employees
- Bonus eligibility for all roles excluding Director and above
- Commission eligibility for Sales roles
- Parental leave program
- 401K program
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Clinical ReviewQuality AuditingProcess ImprovementData AnalysisMedical Necessity PrinciplesTrend IdentificationCorrective Action ImplementationCompliance MonitoringDelegation OversightClinical Criteria Application
Soft Skills
Organizational SkillsAttention to DetailCommunication SkillsCollaborationIndependent Work
Tools & Technologies
Clinical Audit ToolsTechnology-Enabled Review ProcessesAI-Supported Audit Processes
Certifications & Qualifications
Licensed Vocational Nurse (LVN)Licensed Practical Nurse (LPN)
Industry Keywords
Medicare AdvantageCMS RequirementsUtilization ManagementRegulatory AuditsQuality ImprovementClinical EducationNew-Hire TrainingInterQual Criteria