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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 processes, including the ability to analyze medical records and make evidence-based determinations. Holds an active RN license and possesses strong problem-solving and communication skills to effectively negotiate treatment plans and collaborate with providers.
Highest-signal resume keywords
Active RN LicenseUtilization Review CertificationClinical Practice ExperienceEvidence-Based Criteria ApplicationMedical Record Analysis
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 ReviewMedical Record AnalysisTreatment Plan NegotiationUtilization Review SoftwareEvidence-Based CriteriaClinical Information DocumentationProductivity Goal AchievementAudit Score MaintenanceKeyboarding AbilityMulti-Priority Management
Soft Skills
Clear ThinkingExcellent JudgmentProblem SolvingDiscretionStress Management
Certifications & Qualifications
Utilization Review Certification
Industry Keywords
Treatment Plan RequestsPhysician Advisor ServicesClaim ExaminersJurisdictional GuidelinesClinical Practice
About the role
Key responsibilities & impact- Identify treatment plan requests and obtain and analyze supporting medical records
- Clarify unclear treatment plan requests by contacting requesting provider offices
- Use evidence-based criteria and jurisdictional guidelines to make utilization review determinations
- Pursue Physician Advisor services when requests do not meet evidence-based criteria
- Negotiate treatment plan requests with requesting providers when medically appropriate and jurisdictionally allowed
- Channel certified treatment plan requests to preferred vendors as necessary
- Document utilization review outcomes in utilization review software
- Communicate and work with claim examiners to provide clinical information and resolve issues
- Maintain a monthly internal utilization review audit score of 90% or higher
- Meet productivity goals outlined by the supervisor
Requirements
What you’ll need- Active unrestricted RN license in a state or territory of the United States required
- Associate degree from an accredited college or university required
- Utilization review based certification preferred
- Four (4) years of related experience or equivalent combination of education and experience required
- Two (2) years of recent clinical practice or one (1) year of recent utilization review
- Clear and conceptual thinking ability
- Excellent judgment, troubleshooting, problem solving, analysis, and discretion
- Ability to handle work-related stress
- Ability to handle multiple priorities simultaneously
- Ability to meet deadlines
- Computer keyboarding ability
- Hearing, vision, and talking abilities
Benefits
Comp & perks- Blended work environment
- On-going learning and professional growth opportunities
- Diverse and comprehensive benefits package
- Three medical plans to choose from
- Two dental plans to choose from
- Tuition reimbursement eligibility
- 401K plan matching 50% of contributions up to the first 6% saved
- 4 weeks PTO during the first full year
- Vision insurance
- Disability insurance
- Life insurance
- Employee assistance program
- Flexible spending or health savings account
- Additional voluntary benefits