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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 Care Management, applying evidence-based guidelines and regulatory standards to ensure high-quality, cost-effective patient care. Proficient in clinical assessments, communication with stakeholders, and mentoring staff in a dynamic healthcare environment.
Highest-signal resume keywords
Registered Nurse (RN) LicenseBachelor of Science in Nursing (BSN)Utilization Management ExperienceEvidence-Based Guidelines ApplicationStrong 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
Clinical Nursing ExperienceCare ManagementMedical Record ReviewDisease Management UnderstandingConflict ResolutionPatient NavigationTreatment PlanningHealth PromotionBehavioral Health KnowledgeDischarge Planning
Soft Skills
Self-MotivatedPositive AttitudeFlexibilityMentoringCollaboration
Tools & Technologies
Microsoft OfficeMultiple MonitorsInternet TroubleshootingVideo Conferencing (Microsoft Teams)
Certifications & Qualifications
Registered Nurse (RN) LicenseBachelor of Science in Nursing (BSN)
Industry Keywords
Utilization ReviewNCQA GuidelinesCMS RegulationsMedical NecessityCare SettingsTransitions of CareHealthcare CompliancePatient EducationInpatient Hospital SettingHealth Coaching
About the role
Key responsibilities & impact- Perform utilization review care management screenings, assessments, and evaluations
- Develop and implement plans promoting cost-effective, high-quality care
- Review and investigate medical records to assess benefit utilization and medical necessity
- Apply evidence-based guidelines such as InterQual and MCG and medical policies for prior authorization and post-service reviews
- Follow NCQA, CMS, state, and plan regulatory guidelines
- Communicate clearly and accurately with members, providers, and internal and external partners
- Engage providers to support safe, efficient care, appropriate care settings, and transitions of care
- Collaborate with physicians, staff, members, and families to expedite authorizations and direct patients to medically necessary care and appropriate service settings
- Resolve queries regarding authorizations, treatment plans, and medical necessity determinations
- Mentor and guide UM LPN and non-clinical staff on processes, clinical questions, and resource application
- Provide enterprise-wide shift coverage for Peaks, Canyons, and Desert regions
- Work an average of two days per week, including two weekends per eight-week schedule and holiday coverage
- Work 8:00 AM–5:00 PM
Requirements
What you’ll need- Current Registered Nurse (RN) license in state of practice and compact licensure within service area
- Bachelor of Science in Nursing (BSN) from an accredited institution; degree verification required
- RNs hired or promoted into this role must obtain their BSN within four (4) years of hire or promotion date
- Demonstrated experience in care management/navigation or a closely related field, including Utilization Management, discharge planning, managed care, health promotion, health coaching, behavioral health, or Patient Educator roles
- Demonstrated clinical nursing experience in an inpatient hospital setting
- Familiarity with hospital patient-related terminology and processes
- Understanding of disease management, including treatment, length of stay, barriers to delivery of care, and variations
- Strong written and verbal communication and conflict resolution skills
- Basic computer hardware setup and ability to customize computer settings, use multiple monitors, and independently troubleshoot internet and applications
- Knowledge of Microsoft Office software
- Ability to work independently, be self-motivated, maintain a positive attitude, and remain flexible in a rapidly changing environment
- Candidates must not reside or plan to reside in California, Connecticut, Hawaii, Illinois, Massachusetts, Maine, Minnesota, New York, Pennsylvania, Rhode Island, Virginia, Vermont, or Washington
- Video interview through Microsoft Teams required
Benefits
Comp & perks- Generous benefits package covering programs supporting wellness, security, connection, and engagement
- Remote work options and company equipment expectations for approved remote roles