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Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in prospective utilization review and medical necessity determinations, with a strong focus on clinical documentation and adherence to guidelines. Proficient in managing multiple healthcare software systems while maintaining productivity and quality standards.
Highest-signal resume keywords
RN Or LPN/LVN LicenseUtilization Review ExperienceClinical Documentation SkillsProficiency In Microsoft OfficeKnowledge Of InterQual Or MCG
About the role
Key responsibilities & impact- Perform prospective utilization review of prior authorization requests to determine whether requests meet medical necessity criteria
- Apply HealthHelp clinical guidelines, client medical policies, and applicable state and federal requirements
- Identify clinical indications, criteria met or not met, and missing documentation
- Approve requests meeting criteria and refer non-qualifying requests to Physician Reviewers with concise clinical summaries
- Meet daily productivity, quality, and turnaround-time standards
- Document reviews accurately according to HealthHelp’s documentation policy
- Contact providers, office staff, and members to obtain clinical information and communicate determinations
- Handle escalated and expedited cases
- Support Physician Reviewers and Medical Directors in meeting review timeframes
- Identify and refer potential quality-of-care concerns to UM Leadership
- Participate in quality management activities, including QA audits and calibration
- Keep current with guideline, policy, and regulatory updates
- Work across multiple computer systems to manage cases and document reviews
- Collaborate with client personnel and internal teams to resolve concerns
- Perform related duties and projects as assigned
Requirements
What you’ll need- Graduate of an accredited RN or LPN/LVN nursing program
- Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory
- Minimum of two (2) years of experience reviewing prior authorization or utilization review requests against clinical criteria
- Ability to work in a production environment with daily productivity and quality standards
- Accurate, efficient typing and clinical documentation skills
- Proficiency in Microsoft Office
- Ability to learn new healthcare software and work in several systems at once
- Reliable high-speed internet and a private, HIPAA-compliant home workspace
- Preferred: experience making prospective medical necessity determinations at a health plan, utilization management organization, specialty or radiology benefit manager, or workers’ compensation utilization review program
- Preferred: track record of meeting a measured daily case target and QA or accuracy standard
- Preferred: working knowledge of InterQual, MCG, ODG, or other evidence-based criteria sets
- Preferred: working knowledge of Medicare National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs)
- Preferred: review experience in Diagnostic Imaging, Cardiology, Musculoskeletal, Oncology, Sleep, Genetic Testing, or another HealthHelp program area
- Preferred: multistate (compact) nursing license
- Preferred: experience working remotely
Benefits
Comp & perks- Structured new employee orientation on HealthHelp’s clinical guidelines and review platform
- Production ramp period with regular QA audits and coaching
- Fully remote work
- Performance-based bonuses, incentive pay, or commissions may be available
- Reliable high-speed internet and private HIPAA-compliant home workspace required for remote work
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 ReviewClinical DocumentationMedical Necessity DeterminationPrior Authorization ReviewQuality Assurance AuditsTyping SkillsHealthcare Software ProficiencyGuideline ApplicationCase ManagementEscalated Case Handling
Soft Skills
Communication SkillsCollaborationAttention To DetailProblem-SolvingTime Management
Tools & Technologies
Microsoft OfficeHealthHelp SoftwareElectronic Health RecordsClinical GuidelinesHIPAA Compliance Tools
Certifications & Qualifications
RN LicenseLPN LicenseCompact Nursing License
Industry Keywords
Medical Necessity CriteriaPrior AuthorizationUtilization ManagementQuality ManagementDiagnostic ImagingCardiologyOncologyMedicare NCDsLCDsHealthcare Policies