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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 pre-certification and appeals management, while ensuring compliance with regulations and maintaining patient confidentiality. Proficient in using Meditech and other relevant tools to manage clinical information and support discharge planning.
Highest-signal resume keywords
Utilization Review ExperiencePre-Certification ManagementRN CertificationMeditech ProficiencyExcellent Communication 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
Utilization ReviewPre-CertificationMedical TerminologyAnatomy and PhysiologyPediatric NursingComputer ProficiencyWord ProcessingProblem-SolvingClinical Information SubmissionInsurance Procedures
Soft Skills
Detail-OrientedOrganizational SkillsTime ManagementCustomer ServiceConfidentiality
Tools & Technologies
MeditechTrace ProductsInsurance Websites
Certifications & Qualifications
Associates DegreeBachelor's Degree (Preferred)RNRHIA
Industry Keywords
Utilization ManagementCompliancePatient CareInsurance CoordinationDischarge Planning
About the role
Key responsibilities & impact- Perform pre-certification and extended-stay reviews for patients
- Ensure inpatient and observation admissions are pre-certified within required time frames
- Obtain initial pre-certification for emergency-room admissions and notify insurance companies
- Review and submit patient clinical information to insurance companies
- Verify or obtain pre-certification for direct physician-office admissions and insurance-required procedures
- Enter pre-certification numbers, approved days, extended days, and next clinical update dates into Meditech
- Maintain paper and electronic utilization-review records
- Use Meditech, Trace Products, and insurance websites to obtain pre-certification
- Participate in discharge planning
- Process concurrent, retrospective, and second-level retrospective appeals
- Process retrospective eligibility for assigned-insurance accounts
- Actively participate on the Utilization Management Committee
- Train new utilization management coordinators on telephones, Meditech, Trace Products, and insurance websites
- Maintain compliance with applicable laws and regulations
- Assist outside reviewers and collaborate with physicians, practitioners, physician advisors, insurance representatives, and hospital departments
- Maintain confidentiality and provide courteous, professional customer service
- Obtain and maintain pre-certification for inpatient, observation, and same-day surgery patients
- Perform other assignments as requested
Requirements
What you’ll need- Associates Degree required; Bachelor's preferred
- Degree in Nursing or Health Information Administration
- RN and/or RHIA required
- 2 or more years of Utilization Review experience
- Knowledge of medical terminology, anatomy and physiology, and pediatric nursing experience
- Excellent communication skills
- Detail-oriented with organizational and time management skills
- Proficient in computers, word processing, and computer applications
- Problem-solving skills
- Proficient in using reference materials and resources
- Ability to perform required physical duties, including lifting, pushing, and pulling up to specified weights
- Ability to maintain confidentiality and comply with applicable laws and regulations