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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 authorization of services for Medicaid enrollees and thorough documentation of medical information. Proficient in evaluating eligibility and making informed decisions based on established criteria while effectively communicating with clinical reviewers and providers.
Highest-signal resume keywords
Utilization ReviewMedical Record ReviewEligibility VerificationHealth Care Policy AnalysisElectronic Health Records
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 ReviewEligibility VerificationHealth Care Policy AnalysisResearching Health Care ServicesAnalyzing Health Care ProgramsPre-Authorization DecisionsDocumentation SkillsTime ManagementNavigating Electronic Health Records
Soft Skills
Communication SkillsInterpersonal SkillsProblem-Solving SkillsAttention to DetailOrganizational Skills
Tools & Technologies
Workflow Documentation SystemComputer SoftwareElectronic Health Records
Industry Keywords
MedicaidHome and Community-Based ServicesManaged Care EnvironmentHealth or Human Services Degree
About the role
Key responsibilities & impact- Perform utilization review to authorize services for individuals enrolled in Medicaid
- Apply program policies and verify medical, technical, and financial eligibility
- Review medical records and issue pre-authorization decisions
- Provide review decisions for prospective reviews using established criteria
- Screen situations to determine whether care is appropriate
- Refer cases failing criteria to a Case Manager Supervisor
- Complete reviews thoroughly and within specified timeframes
- Serve as liaison among clinical reviewers, providers, facilities, and/or subscribers
- Document medical information supporting decisions in the workflow documentation system
- Respond to provider and consumer email and phone inquiries
- Perform miscellaneous assigned duties
Requirements
What you’ll need- Bachelor’s degree in health or human services and/or equivalent experience
- At least 1 year of experience in utilization review or 1 year of experience evaluating, analyzing, researching and developing health care services, policies and programs
- Knowledge of home and community-based services (preferred)
- Experience working in an insurance or managed care environment (preferred)
- Intermediate PC skills, including navigating electronic health records and other computer software (preferred)
- Experience with utilization review of medical services (preferred)
- Must not require sponsorship for work authorization now or in the future
Benefits
Comp & perks- General benefits and other compensation available as described in Telligen's Benefits Summary
- 100% employee-owned company with employees sharing in company success
- Equal Opportunity Employer
- Reasonable accommodations during the employment process