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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review processes, including concurrent and retrospective appeals, while effectively communicating with healthcare providers and insurance representatives. Proficient in managing denial data and maintaining accurate records within electronic health systems.
Highest-signal resume keywords
Utilization Review ExperienceRN Licensure in TennesseeHealth Information Administration DegreeStrong Computer SkillsInterpersonal Skills
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Concurrent Appeals ProcessingRetrospective Appeals ProcessingMeditech Electronic Health RecordData ManagementPatient Account Denials
Soft Skills
Strong Interpersonal SkillsAbility to Prioritize WorkEffective Communication
Certifications & Qualifications
RN LicensureRHIA Certification
Industry Keywords
Utilization ManagementHealthcare ProvidersManaged Care OrganizationsDenial and Appeal DataPatient Information Submission
About the role
Key responsibilities & impact- Perform concurrent and retrospective appeals for patient account denials at East Tennessee Children's Hospital
- Review appeals received from Utilization Management Coordinators
- Submit patient information to Executive Health Resources for peer-to-peer phone calls during concurrent reviews
- Process retrospective appeal packages and submit them to Executive Health Resources by mail or fax
- Maintain an accurate, up-to-date spreadsheet for concurrent, retrospective, external, and second-level appeals
- Process second-level and external appeals when initial appeals are denied
- Enter appeal and denial information into the Meditech Electronic Health Record
- Prepare monthly denial and appeal data for the Utilization Management Committee
- Assist utilization management precertification processes during high-volume months and staff shortages
- Actively participate in the Utilization Management Committee
- Consult, interact with, and assist physicians, physician advisors, and practitioners
- Process and monitor appeals for inpatient, observation, and same-day surgery accounts
- Communicate with insurance and other outside representatives
- Assist interdepartmental and hospital coworkers as needed
- Accept other assignments as requested
- Utilize hospital resources and time respectfully and accountably
Requirements
What you’ll need- Associate's degree required; bachelor's degree preferred
- Degree in Nursing or Health Information Administration
- RN licensure in the State of Tennessee OR RHIA required
- 5 or more years of Utilization Review experience
- Strong computer skills
- Ability to prioritize work and meet specific objectives under time constraints
- Strong interpersonal skills
- Ability to interact with persons of varying backgrounds and education levels
- Ability to interact effectively with healthcare providers and managed care organizations
- Strong English grammar and spelling skills
- Supervisory responsibilities
- Ability to perform required physical tasks, including heavy lifting, pushing, and pulling up to 50 lbs occasionally, 20–30 lbs frequently, and 10 lbs constantly
- Frequent bending, walking, sitting, squatting, reaching, and standing
- Keyboard/computer use and repetitive motions may be required
Benefits
Comp & perks- Hybrid work arrangement
- Full-time day schedule
- Reasonable accommodations for individuals with disabilities