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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting medical reviews and audits of claims, with a strong understanding of CPT, ICD-10, and HCPCS codes. Possesses the ability to navigate managed care regulations and effectively communicate clinical determinations while maintaining compliance with privacy standards.
Highest-signal resume keywords
Claims AuditingUtilization ManagementVocational Nurse (LVN) LicenseKnowledge of Medi-Cal and MedicareClinical Review and Judgment
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 ReviewData AnalysisClinical Criteria KnowledgeInpatient and Outpatient Case ManagementCPT CodingICD-10 CodingHCPCS CodingHospital Revenue CodesPrior Authorization ProtocolsDenial Management
Soft Skills
Communication SkillsAttention to DetailCollaborationSound Clinical JudgmentAdaptability
Tools & Technologies
Microsoft WordMicrosoft Excel
Certifications & Qualifications
Vocational Nurse (LVN) License
Industry Keywords
Managed CareMedi-CalMedicareHEDISCAHPSNCQA AccreditationClinical PathwaysQuality Program GoalsEthical Audit PracticesPHI Compliance
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
- Make recommendations to improve the claim authorization process and business rules between Claims and UM teams
- Exercise independent judgment in conducting claims reviews
- Support key clinical determinations in alignment with guidance from the Supervisor, Integrated Transitional Care
- Report to the Supervisor, Integrated Transitional Care
- Incorporate IEHP’s Quality Program goals, including HEDIS, CAHPS, and NCQA Accreditation
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 (e.g., InterQual, Milliman, Apollo)
- Knowledge of Medi-Cal, Medicare and other state/federal Program & 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 clinical review and judgement
- Data analysis and trend identification skills
- Communication skills (both written and verbal)
- Ability to exercise sound clinical judgement with minimal supervision
- Ability to escalate appropriately to 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 with the ability to multi-task
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