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Utilization Review Nurse
WVU Medicine. Collaborate with the Medical Director to decrease care variance and ensure timely discharges .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in Utilization Management and care management processes, including Prior Authorization and Concurrent Reviews, while ensuring compliance with federal and state regulations. Strong communication and problem-solving skills are essential for collaborating with medical teams and improving healthcare outcomes.
Highest-signal resume keywords
Registered Nurse LicenseUtilization Management ExperienceInterQual KnowledgeMedical Management ExperienceHealthcare Clinical Experience
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Care Management Review ProcessesPrior AuthorizationConcurrent ReviewsRetrospective ReviewsClinical Guidelines ImplementationData AnalysisProcess Improvement
Soft Skills
Excellent CommunicationProblem SolvingAttention to Detail
Tools & Technologies
Microsoft Office
Certifications & Qualifications
Registered Nurse LicenseBachelor's Degree in NursingAssociate of Science in Nursing Degree
Industry Keywords
NCQA RegulationsDisease ManagementDischarge PlanningMedicare PopulationsMedicaid Populations
About the role
Key responsibilities & impact- Collaborate with the Medical Director to decrease care variance and ensure timely discharges
- Refer members to other plan resources to meet their care conditions
- Report to the Health Plan Manager of Utilization Management
- Serve as an integral member and collaborative contributor of the health plan’s medical management team
- Assist with building and implementing care management review processes, including Prior Authorization, Predetermination, Concurrent Reviews, and Retrospective Reviews
- Implement care management reviews according to established criteria, clinical guidelines, and policies
- Ensure collaborative interventions focused on maximizing members’ healthcare outcomes
- Understand and support the Peer-to-Peer Review process with Medical Directors
- Educate internal and external stakeholders and partners
- Collaborate with the medical management team to identify members who may benefit from coaching or case management interventions
- Understand collected data and work with team members to improve outcomes
- Pursue continuous learning and process improvement across Utilization Management
Requirements
What you’ll need- Current Registered Nurse license issued by the state in which services will be provided or current multi-state Registered Nurse license through the enhanced Nurse Licensure Compact (eNLC)
- Three (3) years of healthcare clinical experience
- Working knowledge of InterQual and/or Milliman Care Guidelines
- Demonstrated knowledge of federal and state laws, NCQA and industry regulations related to disease management, utilization management, case management and discharge planning
- Excellent written and oral communication
- Problem solving capabilities to drive improved efficiencies and customer satisfaction
- Attention to detail
- Proficiency with Microsoft Office
- Occasional weekend and holiday work may be required
- Preferred: Bachelor's Degree in Nursing or Associate of Science in Nursing Degree (ASN); currently enrolled in a BSN program and BSN completion within three (3) years of hire
- Preferred: Medical Management experience for Medicare and/or Medicaid populations
- Preferred: Utilization Management experience
Benefits
Comp & perks- Full-time, 40 scheduled weekly hours
- Exempt status
- Remote work location
- Occasional weekend and holiday work may be required