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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 Case Management, with a strong focus on medical necessity evaluations, interdisciplinary collaboration, and adherence to state and federal regulations. Proficient in maintaining accurate documentation and supporting operational excellence in patient-centered care.
Highest-signal resume keywords
Licensed Practical Nurse (LPN) or Registered Nurse (RN)Utilization Review ExperienceCase Management ExperienceInterQual Software KnowledgeMCG Certification
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Medical Necessity DeterminationClinical DocumentationData EntryQuality Concern IdentificationTreatment Plan Collaboration
Soft Skills
Strong Communication SkillsAttention to DetailOrganizational SkillsTime Management SkillsClinical Judgment
Tools & Technologies
InterQual SoftwareMCG Medical Necessity Criteria Software
Certifications & Qualifications
InterQual CertificationMCG Certification
Industry Keywords
Healthcare SystemInsurance OrganizationState and Federal RegulationsUtilization ManagementPatient-Centered Care
About the role
Key responsibilities & impact- Perform admission, concurrent, retrospective, and Medicare reviews to determine medical necessity and support appropriate levels of care
- Collaborate with Case Managers, providers, and insurance companies on treatment plans, authorization reviews, denial prevention, and discharge planning
- Document clinical reviews, payer communications, treatment delays, avoidable days, and other case management activities
- Maintain accurate records and databases, organize clinical information, and support utilization reviews
- Identify quality concerns, report potential issues, and provide guidance on case management processes and payer requirements
- Participate in departmental initiatives, process improvement efforts, and ongoing learning
- Support operational excellence and high-quality, patient-centered care at Memorial Sloan Kettering Cancer Center
Requirements
What you’ll need- Licensed Practical Nurse (LPN) or Registered Nurse (RN) with a current, active state license required
- Minimum 2 years of Utilization Review and/or Case Management experience within a healthcare system or insurance organization required
- Knowledge of InterQual software and/or MCG Medical Necessity criteria software
- Knowledge of state and federal regulations governing health insurance coverage and utilization management
- InterQual or MCG Certification highly preferred
- Strong communication skills for collaboration with interdisciplinary teams, insurance payers, and other stakeholders
- Sound clinical judgment and ability to analyze clinical information, make utilization review decisions, and escalate concerns
- Strong attention to detail for medical record reviews, documentation, and data entry
- Excellent organizational and time management skills
- Ability to prioritize competing priorities and maintain accurate, timely documentation
- Schedule availability: 8am-4pm, Monday through Friday
Benefits
Comp & perks- Hybrid work program eligibility after successful completion of a six-month probationary period, in accordance with departmental guidelines
- Benefits offerings referenced by MSK
- Reasonable accommodations for qualified individuals with disabilities