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Posted: 10/21/2026Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical utilization management, including the application of evidence-based criteria and regulatory compliance. Proficient in managing case reviews, mentoring staff, and utilizing analytical tools to enhance operational efficiency.
Highest-signal resume keywords
Clinical Subject Matter ExpertUtilization Management ExperienceEvidence-Based Criteria ApplicationRegulatory Compliance KnowledgeStrong Analytical Skills
About the role
Key responsibilities & impact- Serve as the clinical subject matter expert for assigned programs and modalities
- Answer nurses’ criteria, guideline, and process questions
- Perform prospective case reviews while maintaining Team Lead productivity and quality standards
- Handle complex, escalated, and expedited cases and escalated inbound provider calls and requests
- Interpret HealthHelp clinical guidelines, client medical policies, and regulatory requirements
- Coordinate daily physician reviewer case flow and notifications
- Monitor case inventory, queues, and turnaround times
- Adjust the nurse assignment tool based on staffing, proficiency, request type, and volume
- Use productivity, turnaround-time, and queue reports to identify backlogs, outliers, and trends
- Recommend staffing or workflow changes to the Supervisor
- Use AVAYA, ADP Workforce Now, and related systems to manage phone and staffing metrics
- Audit nurse case work for determination appropriateness, documentation, and denial-related language
- Support new nurses through orientation and ramp with QA audits and feedback
- Conduct regular one-on-ones with Clinical Review Nurses
- Recommend improvements to clinical review processes, criteria application, tools, and job aids
- Provide secondary Nursing Management coverage when the Supervisor or Manager is unavailable
- Communicate assignments, expectations, and changes to frontline staff
- Resolve or escalate day-to-day issues and foster a respectful team environment
- Lead or participate in team meetings
- Collaborate with departments and client personnel to resolve concerns and obtain clarifications
- Ensure compliance with benefit management, HIPAA, state and federal regulations, URAC, and NCQA standards
- Refer complaints to the Compliance Officer and work with Quality to investigate and correct errors
- Evaluate and report HIPAA breaches
- Perform other related duties and projects as assigned
Requirements
What you’ll need- Graduate of an accredited school of nursing
- Current, active, unrestricted RN or LPN/LVN license in a U.S. state or territory
- Minimum of three (3) years of prospective utilization management experience making medical necessity determinations
- Experience auditing or reviewing other reviewers’ case work, precepting or training new staff, or serving as a go-to clinical resource for a team
- Sustained performance at or above productivity and quality standards in the current or most recent review role
- Expert application of evidence-based criteria such as InterQual, MCG, or proprietary guidelines across more than one program or modality
- Working knowledge of utilization management regulatory and accreditation requirements, including URAC, NCQA, CMS and state turnaround times, Medicare NCDs/LCDs, and denial notice requirements
- Strong analytical skills and proficiency using Excel, including sorting, filtering, formulas, and pivot tables
- Ability to manage inventory and multiple priorities in a fast-paced, changing environment
- Clear, professional written and verbal communication, including giving constructive feedback
- Proficiency in Microsoft Office: Outlook, Excel, Word, and PowerPoint; Visio is a plus
- HIPAA-compliant remote location with reliable high-speed internet
- Availability for a shift within 7:00 AM–7:00 PM CT, potentially including a late shift
- After-hours on-call may be required
- Ability to use the telephone, sit, enter data, and view a PC screen for up to 8 hours
- Ability to prioritize in a multi-task environment
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
ATS Keywords
✓ Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Prospective Utilization ManagementMedical Necessity DeterminationsCase Review AuditingExcel ProficiencyInterQual ApplicationMCG Guidelines ApplicationDocumentation ReviewData ManagementQuality Assurance AuditsMulti-Priority Management
Soft Skills
Clear CommunicationConstructive FeedbackTeam CollaborationProblem-SolvingMentoring
Tools & Technologies
AVAYAADP Workforce NowMicrosoft OfficeExcelOutlookWordPowerPointVisio
Certifications & Qualifications
Active RN LicenseLPN/LVN License
Industry Keywords
HIPAA ComplianceURAC StandardsNCQA StandardsCMS RegulationsMedicare NCDs/LCDsDenial Notice Requirements