FREE ACCESS
5,000–10,000 jobs/day
See all jobs on Scoutfield
Search thousands of fresh jobs every day.
Discover
- Fresh listings
- Fast filters
- No subscription required
Create a free account and start exploring right away.
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical nursing or therapy, with a strong focus on utilization review and case management. Proficient in applying clinical guidelines and decision support tools to ensure high-quality, cost-effective care transitions.
Highest-signal resume keywords
Utilization ReviewClinical Decision Support ToolsMCG GuidelinesActive RN, OT, or PT LicenseCase Management
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 NursingTherapy ExperiencePrior Authorization ReviewsMedical Necessity DeterminationCare Coordination
Soft Skills
CollaborationCommunicationProblem-Solving
Tools & Technologies
Microsoft OfficeInterQual
Certifications & Qualifications
Active RN LicenseActive OT LicenseActive PT License
Industry Keywords
Managed Care RegulationsPost-Acute Care ServicesHealthcare CompliancePatient EvaluationsCare Transitions
About the role
Key responsibilities & impact- Review medical records to determine medical necessity
- Conduct patient evaluations, manage admissions and informational visits, and ensure timely post-discharge follow-ups with completed assessments to help prevent acute care readmissions
- Review requests for post-acute services using established clinical guidelines and coverage criteria
- Collaborate with physicians, healthcare providers, and internal and external stakeholders to support improved health outcomes
- Coordinate care with facilities and providers throughout the medical management process
- Consult with peer reviewers, Medical Directors, or delegated clinical reviewers to ensure care is medically appropriate, high-quality, and cost-effective
- Conduct prior authorization reviews and/or continued stay reviews for post-acute care services
- Escalate cases to medical directors as needed
- Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria
- Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions
- Participate in team meetings, educational activities, and interrater reliability testing
- Ensure compliance with federal, state, and accreditation standards and identify opportunities to enhance communication or processes
- Support payer programs and initiatives related to the post-acute space
- Make benefit determinations about appropriate levels of care using clinical guidelines
- Coordinate benefits and transitions between various areas of care
- Utilize healthcare-system resources to assist physicians and patients
- Perform other job duties as assigned
Requirements
What you’ll need- Bachelor's degree or equivalent work experience
- 4-6 years of clinical nursing or therapy experience
- Active RN, OT, or PT license
- 1-2 years' experience in utilization review, case management and/or managed care regulations
- Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes
- Working knowledge of Microsoft Office applications (e.g., Word, Excel)
- Comfortable using clinical decision support tools and operational software
- Willing to travel up to 30% based on business needs
- Willing to work additional or irregular hours as needed
- Must work in accordance with applicable security policies and procedures to safeguard company and client information
- Must be able to sit and view a computer screen for extended periods of time
- Applicants for U.S.-based positions with WellSky must be legally authorized to work in the United States
- Certain client-facing positions may be required to comply with applicable requirements, such as immunizations and occupational health mandates
Benefits
Comp & perks- Excellent medical with Rx, dental, and vision benefits
- Mental Health support through EAP
- Generous paid time off, plus 13 paid holidays
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year