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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical review and utilization management, with a strong focus on applying InterQual and MCG criteria for emergency department admissions. Proficient in electronic medical record review and effective communication with healthcare professionals to ensure appropriate resource utilization.
Highest-signal resume keywords
Current RN LicenseUtilization Management ExperienceInterQual Criteria ProficiencyElectronic Medical Record ReviewClinical Experience in Acute Care
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 ManagementMedical Necessity ScreeningEvidence-Based Clinical GuidelinesData AnalysisResource Utilization AssessmentTelephonic CommunicationMicrosoft Office SuiteBasic Excel Proficiency
Soft Skills
AdaptabilityAbility to Thrive in Fast-Paced Environment
Certifications & Qualifications
CCMACMCMCNCMGT-BC
Industry Keywords
Emergency DepartmentAcute Care SettingClinical ExperienceConcurrent ReviewsHealthcare Resources
About the role
Key responsibilities & impact- Review and evaluate electronic medical records for emergency department admissions
- Screen admissions for medical necessity using InterQual or MCG criteria
- Apply evidence-based clinical guidelines to assess appropriate utilization of healthcare resources
- Participate in telephonic discussions with emergency department physicians regarding documentation and admission status
- Enter clinical review information into the system for transmission to insurance companies for authorization
- Review, analyze, and identify utilization patterns, trends, problems, or inappropriate resource utilization
- Work assigned shifts between 9am EST and 9pm EST
- Adjust availability or work different shifts based on client needs and operational demands
Requirements
What you’ll need- Current and unrestricted RN license
- At least 3 years of clinical experience in an acute care setting in emergency room, critical care and/or medical/surgical nursing
- At least 2 years of utilization management experience in acute admission and concurrent reviews
- Intermediate-level experience with InterQual and/or MCG criteria within the last two years
- Proficiency in medical record review in an electronic medical record (EMR)
- Experience with Microsoft Suite, including Office and basic Excel
- Ability to thrive in a fast-paced, dynamic environment and adapt to frequently changing business needs
- Passing score(s) on job-related pre-employment assessment(s)
- All applicants must be legally authorized to work in the United States
- No work visa sponsorship is provided
- Preferred: at least 5 years of clinical experience in an acute care setting
- Preferred: at least 3 years of utilization management experience within the hospital setting
- Preferred: Bachelor’s of Science in Nursing (BSN)
- Preferred: case management certifications such as CCM, ACM, CMCN, or CMGT-BC
Benefits
Comp & perks- Comfortable with remote work arrangements and virtual collaboration tools
- Full-time schedule includes 4 holidays per year
- Full-time schedule includes every other weekend or 4 weekend shifts per month
- Weekend FT schedule available: 3 twelve-hour shifts, including one weekday shift
- Pre-employment background check and drug screen provided at Netsmart’s sole expense