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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review and utilization management, with a strong focus on inpatient medical necessity assessments and adherence to regulatory guidelines. Proven ability to communicate effectively with multidisciplinary teams and external providers while maintaining high standards of productivity and quality.
Highest-signal resume keywords
MD Or DO5 Or More Years Post-Residency Clinical ExperienceActive, Unrestricted Medical LicenseCurrent Board Certification In An AOABPS- Or ABMS-Recognized SpecialtyExperience In Utilization Management Or Inpatient Review
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 ReviewMedical Necessity AssessmentUtilization ManagementInpatient ExposureAnalytical SkillsDocumentation SkillsFamiliarity With MCG Or InterQual GuidelinesExperience With Medicare PopulationsClinical Technology ProficiencyProcess Improvement
Soft Skills
Strong Communication SkillsAdaptabilityCollaborationCommitment To QualityProfessionalism
Certifications & Qualifications
Board CertificationMedical License
Industry Keywords
CMS RegulationsHumana PoliciesRegulatory RequirementsHospital-Based CasesIntegrated Delivery NetworksMedical Management OrganizationsPHI/HIPAA Compliance
About the role
Key responsibilities & impact- Perform expert clinical review of inpatient medical records
- Assess medical necessity using national guidelines, CMS regulations, Humana policies, and recognized clinical standards
- Analyze complex hospital-based cases and make utilization management determinations
- Communicate with external providers by phone to obtain clinical information and discuss review outcomes
- Conduct inpatient medical necessity reviews in accordance with regulatory requirements
- Maintain productivity, accuracy, quality, and timely completion of assigned tasks
- Communicate review outcomes clearly and professionally in verbal and written formats
- Adapt to changing workflows, tools, and utilization management procedures
- Collaborate in a structured, multidisciplinary team environment
- Support high-quality, consistent decision-making and physician partnerships
- Report directly to a Lead Medical Director
- Participate in organizational committees or special project teams as needed
Requirements
What you’ll need- MD or DO
- 5 or more years post-residency clinical experience
- Active, unrestricted medical license in at least one state and willingness to obtain additional licenses as needed
- Current and ongoing Board Certification in an AOABPS- or ABMS-recognized medical specialty
- Meets all credentialing requirements, with no state or federal sanctions
- Strong analytical, communication, and documentation skills
- Ability to work effectively within a structured environment and as part of a multidisciplinary team
- Inpatient exposure, including hospitalist-level acuity, ED, ICU, or hospital-based FP/IM (preferred)
- Prior experience in utilization management or inpatient review (preferred)
- Familiarity with MCG or InterQual guidelines (preferred)
- Experience providing care for Medicare populations and working in hospitals, integrated delivery networks, or medical management organizations (preferred)
- Adaptability to changes in workflow, regulatory requirements, or clinical systems (preferred)
- Proficiency with clinical technology platforms (preferred)
- Commitment to process improvement and innovation (preferred)
- Must work standard Monday-Friday hours with rotational weekend/holiday coverage
- Must meet work-from-home requirements, including minimum 25 Mbps download and 10 Mbps upload internet speeds and a dedicated workspace protecting PHI/HIPAA information
Benefits
Comp & perks- Bonus incentive plan based on company and/or individual performance
- Medical, dental, and vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company and personal holidays
- Paid parental and caregiver leave
- Short-term and long-term disability
- Life insurance
- Occasional travel to Humana offices for training or meetings
- Remote work arrangement
- Dedicated home workspace and internet requirements supporting work from home