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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Review and Behavioral Health, with a strong focus on insurance authorization processes and clinical documentation standards. Proficient in EMR systems and Salesforce, ensuring compliance with payer requirements and effective communication with facilities.
Highest-signal resume keywords
Licensed Practical Nurse (LPN)Utilization Review ExperienceInsurance Authorization ProcessesEMR Systems ProficiencyBehavioral Health Regulations 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
Utilization ReviewClinical Documentation ReviewCase ManagementPrior AuthorizationDocumentation StandardizationTraining DevelopmentAccuracy MonitoringKnowledge TransferPeer Review CoordinationAuthorization Compliance
Soft Skills
Excellent CommunicationOrganizational SkillsFollow-Up SkillsTask PrioritizationInterpersonal Skills
Tools & Technologies
SalesforceEMR SystemsWorkflow Platforms
Certifications & Qualifications
Licensed Practical Nurse (LPN)
Industry Keywords
Behavioral HealthMedical Necessity CriteriaLevels of CareDocumentation GapsAuthorization Approvals
About the role
Key responsibilities & impact- Lead training for new onshore Representatives and oversee development of payer-specific training materials
- Conduct CDI and documentation standardization training across customers
- Partner with QA to perform ongoing utilization review audits and monitor accuracy trends
- Provide educational feedback to facilities on supporting documentation required for authorization approvals
- Support knowledge transfer to Training Leads and disseminate new payer/process updates
- Conduct administrative, concurrent utilization, and retrospective reviews via live, voicemail, fax, and portal reviews
- Coordinate peer reviews as needed
- Provide Assignment of Responsibility form templates at admission when required
- Enter utilization review authorization information into facility EMR billing systems and internal workflow systems
- Follow up on pending authorizations to secure approvals and documentation
- Document and track utilization review activities in Salesforce and designated systems
- Assist with document retrieval from EMRs
- Act as liaison between facilities and internal teams
- Send morning and end-of-day facility status updates and weekly stakeholder summaries
- Maintain understanding of levels of care, insurance authorization requirements, and behavioral health regulations
- Identify documentation gaps affecting authorization approvals
- Review clinical documentation from a licensed nursing perspective and communicate charting deficiencies to facilities
- Serve as clinical resource for escalations and complex case reviews
- Ensure authorization requests comply with policies and payer requirements
- Perform additional utilization review and prior authorization duties as assigned
Requirements
What you’ll need- Active and unrestricted Licensed Practical Nurse (LPN) credential
- Minimum of 2 years of Behavioral Health Clinical, Utilization Review, case management, or prior authorization experience preferred
- Knowledge of insurance authorization processes, levels of care, and medical necessity criteria
- Excellent verbal and written communication for facility interactions
- High level of accuracy and strong organizational, follow-up, and documentation skills
- Proficiency in EMR systems, Salesforce, and other workflow platforms
- Ability to prioritize tasks and manage multiple authorization cases simultaneously