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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, including clinical reviews and compliance with medical policies and regulations. Proficient in coordinating healthcare services and collaborating with providers to ensure quality care and efficient service delivery.
Highest-signal resume keywords
Utilization Management ExperienceClinical Review ProficiencyNYS RN LicenseMicrosoft Office Suite ProficiencyMedicare And Medicaid Knowledge
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 ReviewUtilization Management StandardsCoding StandardsClaims ResearchProcess ImprovementDocumentationTelephonic CommunicationElectronic CommunicationOn-Site ReviewsTraining And Mentoring
Soft Skills
Strong Written CommunicationStrong Verbal CommunicationMultitasking AbilityIndependent WorkPresentation Skills
Certifications & Qualifications
NYS RN LicenseAssociates DegreeBachelors Degree Preferred
Industry Keywords
Healthcare ServicesQuality Of CareMedical NecessityProvider RelationsState And Federal MandatesManaged Care Benefit PlansAccreditation ComplianceHealth Plan Service Regions
About the role
Key responsibilities & impact- Coordinate, integrate, and monitor utilization of physical health medical and healthcare services
- Perform pre-service, concurrent, and post-service clinical reviews
- Determine appropriateness and medical necessity of requested services using clinical criteria, medical policies, contractual benefits, and mandates
- Refer appropriate cases and potential quality-of-care or utilization issues to the Medical Director
- Coordinate with Case Management to address member needs and prevent gaps in care
- Conduct reviews telephonically, electronically, or on-site according to customer and departmental needs
- Plan, implement, and document utilization management activities
- Communicate with members, treating physicians, and other providers to obtain clinical information and facilitate needed services
- Collaborate with hospitals, home care, care management, and other providers
- Serve as a resource and liaison to the provider community with Provider Relations
- Interpret clinical criteria, medical policies, contract benefits, and State and Federal Mandates
- Price, code, and research claims as needed
- Meet departmental timeliness, production, metric, and audit requirements
- Maintain regulatory and accreditation compliance and implement changing requirements
- Participate in rotating on-call coverage and perform additional hours as required
- Assist with training and special projects
- Level II: Suggest process improvements, mentor staff, manage complex assignments, participate in committees, and lead when required
- Level III: Provide leadership, identify process efficiencies, maintain procedures, serve as escalation subject matter expert, mentor staff, back up the Supervisor, support orientation and training, and assist the Medical Director with projects
Requirements
What you’ll need- Associates degree and active NYS RN license required
- Bachelors degree preferred
- Minimum of three years of clinical experience required
- Utilization Management experience preferred
- Proficiency with the Microsoft Office Suite
- General understanding of coding standards
- Current and working knowledge of Utilization Management Standards
- Experience interpreting managed care benefit plans and strong knowledge of Medicare and Medicaid contracts and benefits preferred
- Strong written and verbal communication skills
- Ability to multitask and balance priorities
- Ability to work independently on a daily basis
- Level II: Minimum of 2 years in a utilization management position; ability to escalate to management; proficiency in related technology; ability to take on broader responsibilities; ability to participate in training new staff
- Level III: At least 5 years in a utilization management position or similar subject matter expert role; broad understanding of UM and CM; expertise handling complex assignments and challenging situations; ability to lead training; demonstrated presentation skills
- Ability to travel across the health plan service regions as needed
- Ability to work at a computer for prolonged periods
Benefits
Comp & perks- Group health and/or dental insurance
- Retirement plan
- Wellness program
- Paid time away from work
- Paid holidays
- Potential remote work, determined case-by-case
- Opportunity for additional hours, per department needs