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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in medical claims review, authorization processes, and auditing, with a strong understanding of CPT, ICD-10, and HCPCS coding. Proficient in collaboration with clinical teams and navigating managed care regulations to ensure compliance and quality in health plan operations.
Highest-signal resume keywords
Claims AuditingUtilization ManagementCPT/ICD-10/HCPCS KnowledgeVocational Nurse (LVN) LicenseData Analysis
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Claims ReviewClinical JudgmentData EntryTrend IdentificationMedical Record ReviewAuthorization Decision MakingProcess ImprovementRegulatory ComplianceQuality Program GoalsAttention to Detail
Soft Skills
Written CommunicationVerbal CommunicationCollaborationTrust BuildingAdaptability
Tools & Technologies
Microsoft WordMicrosoft Excel
Certifications & Qualifications
Vocational Nurse (LVN) License
Industry Keywords
Managed CareMedi-CalMedicareClinical PathwaysPrior AuthorizationDenial ManagementHEDISCAHPSNCQA AccreditationInterQual
Tech Stack
Tools & technologiesApollo
About the role
Key responsibilities & impact- Conduct timely medical reviews of IEHP facility and professional claims and appeals
- Identify process improvements in the UM/Claims interface and recommend improvements to claim authorization processes and business rules
- Exercise independent judgment in claims reviews and support clinical determinations under Supervisor guidance
- Incorporate IEHP Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
- Audit medical necessity claims according to departmental policies and procedures
- Act as the key clinical interface between Claims and Medical Services
- Attend UM and Claims team meetings
- Review inpatient and outpatient claims requiring authorization, appeals, and other disputed claims to meet regulatory requirements
- Obtain clinical information needed to make authorization decisions for unauthorized claims
- Identify potentially denied services, admissions, or days and present them to the Medical Director
- Review medical records to determine whether charges and services are appropriate, including CPT/HCPCS codes and up-coding practices
- Analyze level of care during inpatient reviews
- Track provider billing trends and report practices requiring further investigation to leadership
- Collaborate with physicians, nurses, ancillary personnel, and others to support communication and customer relations
- Inform staff about coordination and negotiation of financial arrangements for non-contracted and fee-for-service providers and facilities
- Provide reports as necessary
- Adapt to changes and unusual circumstances to minimize workplace disruption
- Perform other duties required to support Health Plan operations and department business needs
Requirements
What you’ll need- A minimum of one (1) year of relevant work experience
- Recent experience with inpatient and outpatient utilization and case management required
- Experience in auditing claims
- Experience in reviewing inpatient medical records and claims preferred
- Experience in managed care, MediCal, Medicare preferred
- High school diploma or GED
- Associate’s degree in health care or a related field from an accredited institution
- Possession of an active, unrestricted, and unencumbered Vocational Nurse (LVN) license issued by the California Board of Vocational Nursing and Psychiatric Technicians required
- Knowledge and understanding of CPT, ICD-10, HCPCS and hospital revenue codes
- Knowledge of nationally recognized clinical criteria, including InterQual, Milliman, and Apollo
- Knowledge of Medi-Cal, Medicare and other state/federal programs and regulations
- Knowledge of foundations of nursing practice and clinical pathways across inpatient, outpatient, and post-acute settings
- Knowledge of health plan policies, prior authorization protocols, appeals processes, and denial management
- Proficient in computer applications such as Word and Excel
- Skilled in data entry
- Skilled in clinical review and judgment
- Data analysis and trend identification skills
- Written and verbal communication skills
- Ability to exercise sound clinical judgment with minimal supervision
- Ability to escalate appropriately to the Medical Director for complex determinations
- Ability to build trust and collaboration with physicians, nurses, ancillary staff, and claims personnel
- Ability to navigate diverse perspectives
- Ability to adjust to policy updates, workflow changes, and unusual circumstances while maintaining service quality
- Ability to handle PHI with strict adherence to privacy and security standards and maintain ethical audit practices
- Strong attention to detail and ability to multitask
Benefits
Comp & perks- Competitive salary
- State of the art fitness center on-site
- Medical Insurance with Dental and Vision
- Life, short-term, and long-term disability options
- Career advancement opportunities and professional development
- Wellness programs that promote a healthy work-life balance
- Flexible Spending Account – Health Care/Childcare
- CalPERS retirement
- 457(b) option with a contribution match
- Paid life insurance for employees
- Pet care insurance