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Utilization Review Nurse
Peak Health. Collaborate with the Medical Director to decrease care variance and ensure timely discharges .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in care management processes, including Prior Authorization and Concurrent Reviews, while ensuring compliance with clinical guidelines and regulations. Strong ability to collaborate with medical teams to enhance member healthcare outcomes and improve utilization management practices.
Highest-signal resume keywords
Registered Nurse LicenseHealthcare Clinical ExperienceInterQual KnowledgeUtilization Management ExperienceMedical Management Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Care Management Review ProcessesPrior AuthorizationConcurrent ReviewsRetrospective ReviewsClinical Guidelines ImplementationData AnalysisProblem SolvingAttention to Detail
Soft Skills
Excellent CommunicationCollaborationCustomer Satisfaction Focus
Tools & Technologies
Microsoft Office
Certifications & Qualifications
Registered Nurse LicenseBachelor's Degree in NursingAssociate of Science in Nursing Degree
Industry Keywords
Utilization ManagementDisease ManagementNCQA RegulationsMedicareMedicaid
About the role
Key responsibilities & impact- Collaborate with the Medical Director to decrease care variance and ensure timely discharges
- Refer members to other health plan resources to meet their care conditions
- Report to the Health Plan Manager of Utilization Management
- Serve as an integral and collaborative member of the health plan’s medical management team
- Assist with building and implementing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews
- Implement care management reviews according to established criteria, clinical guidelines, and policies
- Ensure interventions are collaborative and focused on maximizing member healthcare outcomes
- Work with Medical Directors to improve the Peer-to-Peer Review process and member and Provider Network services
- Educate internal and external stakeholders and partners
- Collaborate with the medical management team to identify members who may benefit from coaching or case management interventions
- Understand collected data and work with team members to improve outcomes
- Participate in lifelong learning and continuous process improvement across Utilization Management
Requirements
What you’ll need- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC)
- Three (3) years of healthcare clinical experience
- Working knowledge of InterQual and/or Milliman Care Guidelines
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning
- Excellent written and oral communication
- Problem solving capabilities to drive improved efficiencies and customer satisfaction
- Attention to detail
- Proficiency with Microsoft Office
- Occasional weekend and holiday work may be required
- Preferred: Bachelor's Degree in Nursing OR Associate of Science in Nursing Degree (ASN); currently enrolled in a BSN program and BSN completion within three (3) years of hire
- Preferred: Medical Management experience for Medicare and/or Medicaid populations
- Preferred: Utilization Management experience
Benefits
Comp & perks- Full-time schedule with 40 scheduled weekly hours
- Exempt status
- Remote work location
- Occasional weekend and holiday work may be required