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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in inpatient utilization reviews, applying InterQual criteria and ensuring compliance with regulatory standards. Proficient in clinical documentation, collaboration with healthcare teams, and delivering quality customer service in a fast-paced environment.
Highest-signal resume keywords
RN LicenseInpatient Utilization ReviewInterQual CertificationClinical DocumentationRegulatory Compliance
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Inpatient Clinical NursingUtilization ManagementCase ManagementMedical Necessity CriteriaLevel-Of-Care DeterminationTransitional Care PlanningInsurance TerminologyMicrosoft OfficeCritical ThinkingDocumentation Updates
Soft Skills
Organizational SkillsTime ManagementWritten CommunicationVerbal CommunicationTeam Collaboration
Certifications & Qualifications
InterQual Certification
Industry Keywords
HIPAAURACNCQAHealthHelp PolicyPayer-Specific Requirements
About the role
Key responsibilities & impact- Perform concurrent inpatient utilization reviews using InterQual criteria to determine medical necessity
- Conduct admission, continued-stay, and transitional-care reviews
- Complete follow-up activities and documentation updates
- Collaborate clinically with attending physicians, hospitalists, and care teams to obtain clinical information and support level-of-care decisions
- Communicate clinical rationale during real-time concurrent review interactions
- Facilitate resolution of escalated cases and refer cases to Physician Reviewers or Specialty Program Medical Directors
- Assist Physician Reviewers and Medical Directors to ensure compliance with review timeframes
- Maintain written documentation according to HealthHelp policy
- Apply regulatory, accreditation, payer-specific, InterQual, and HealthHelp/client medical policies
- Adhere to HIPAA, state, and federal regulations and URAC/NCQA standards
- Support Compliance Department initiatives and updates as a subject matter expert
- Collect and enter confidential information
- Perform clinical intake and review expedited cases
- Support concurrent review coverage, including non-standard hours, weekends, and holidays when required
- Identify and refer quality issues to UM Leadership
- Collaborate with client personnel to resolve customer concerns
- Provide quality customer service to providers, administrative staff, and others
- Participate in the HealthHelp Quality Management Program
- Perform other related duties and projects as assigned
Requirements
What you’ll need- RN graduate from an accredited school of nursing (BSN preferred)
- Current, active unrestricted RN license in the state or territory of the U.S. (USRN equivalent)
- Two (2) years of experience in an acute care setting, required
- Two (2) years of inpatient clinical nursing, utilization management, or case management experience, preferred
- Experience with InterQual or similar evidence-based clinical decision support criteria, preferred
- Willingness to complete and maintain InterQual certification and ongoing competency requirements
- Familiarity with inpatient level-of-care criteria, observation versus inpatient status determinations, and transitional care planning, preferred
- Working knowledge of medical necessity criteria, level-of-care determination standards, and payer-specific utilization review requirements
- Knowledge of insurance terminology
- Experience working with state and federal regulatory and compliance standards, preferred
- Proficient technical skills in Microsoft Office (Word, Excel, and PowerPoint), required
- Good organizational and time management skills
- Excellent written and verbal communication skills
- Ability to utilize critical thinking skills
- Highly motivated, self-starter who can work efficiently and independently, or as a team member
- Flexibility to work weekends or alternative daytime hours based on business needs
- 100% attendance required for the first 90 days
Benefits
Comp & perks- Medical, dental, and vision insurance
- Paid time off (PTO), holidays, and sick leave
- 401(k) with company match or other retirement plan
- Life and AD&D Insurance
- Employee Assistance Program
- Performance-based bonuses, incentive pay, or commissions may be available
- Equipment provided (mini desktop, dual monitors, mouse, keyboard, headset)