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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and Case Management, with a strong focus on Medical Necessity Reviews and adherence to MCG or InterQual guidelines. Proficient in maintaining clinical information in medical management systems while ensuring compliance with HIPAA regulations.
Highest-signal resume keywords
RN License in LouisianaUtilization Management ExperienceMCG or InterQual Guidelines FamiliarityHealth Plan ExperienceProficient with MS Office
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 ManagementCase ManagementMedical Necessity ReviewsDischarge PlanningHome Health ExperienceMCG GuidelinesInterQual GuidelinesClinical JudgmentData Entry in Medical Management SystemsLevel-of-Care Reviews
Soft Skills
Independent Decision-MakingTeam CollaborationProvider EducationCommunication SkillsProblem-Solving
Tools & Technologies
MS OfficeMedical Management Systems
Certifications & Qualifications
Active RN License
Industry Keywords
MedicareMedicaidHealth PlanPHIHIPAA
About the role
Key responsibilities & impact- Review prior authorization requests for appropriate care and setting
- Follow guidelines and policies to approve services or forward requests to appropriate stakeholders
- Complete medical necessity and level-of-care reviews using clinical judgment
- Refer cases to internal stakeholders for review based on findings
- Educate providers on utilization and medical management processes
- Enter and maintain pertinent clinical information in medical management systems
- Interpret varied assignments and independently determine appropriate courses of action
- Work according to department, segment, and organizational strategy and operating objectives
- Make decisions regarding work methods with minimal direction
- Follow established guidelines and procedures
Requirements
What you’ll need- 2+ years of RN experience
- Active RN license in the state of Louisiana
- Ability to be licensed in multiple states without restrictions
- Must be able to work Mon-Fri, Tues-Sat, or Sun-Thurs roles for 8-hour shifts
- Proficient with MS Office products including Word, Excel, and Outlook
- Ability to work independently under general instructions and with a team
- Health Plan experience working with large carriers (preferred)
- Previous Medicare/Medicaid experience (preferred)
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab (preferred)
- Experience working with MCG or InterQual guidelines (preferred)
- Internet service with at least 25 Mbps download and 10 Mbps upload for home or hybrid home/office work
- Dedicated workspace without ongoing interruptions to protect member PHI/HIPAA information
Benefits
Comp & perks- Bonus incentive plan based upon company and/or individual performance
- Medical benefits
- Dental benefits
- Vision benefits
- 401(k) retirement savings plan
- Paid time off
- Company holidays
- Personal holidays
- Paid parental leave
- Paid caregiver leave
- Short-term disability
- Long-term disability
- Life insurance
- Occasional travel to Humana offices for training or meetings