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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in clinical reviews, medical necessity determination, and healthcare reimbursement processes, with a strong focus on ICD-10 coding and DRG assignment. Proficient in utilizing AI-enabled tools and maintaining compliance with regulatory requirements while effectively communicating with payers and clients.
Highest-signal resume keywords
Active RN Or LPN LicenseClinical Nursing ExperienceUtilization Review ExperienceICD-10 And DRG FamiliarityExperience With AI-Enabled Tools
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 ReviewMedical Necessity DeterminationHealthcare ReimbursementUtilization ManagementDenials And Appeals ManagementClinical Documentation ReviewCase ManagementAuditingCodingElectronic Medical Records
Soft Skills
Effective CommunicationAnalytical ThinkingAttention To DetailProblem SolvingCollaboration
Tools & Technologies
AI-Enabled ToolsMicrosoft WordMicrosoft ExcelEpicCernerMeditechInterQualMCG
Certifications & Qualifications
Case Management CertificationCoding CertificationUtilization Review Certification
Industry Keywords
CMS RequirementsTwo-Midnight RuleClinical Documentation Improvement (CDI)ACDISPayer Policies
About the role
Key responsibilities & impact- Perform clinical reviews in accordance with managed care, payer, and CMS requirements
- Assist with determining appropriate level of care and medical necessity
- Review clinical documentation related to ICD-10 coding and DRG assignment
- Support denial management and preparation of appeal correspondence
- Evaluate whether documentation supports the care provided and applicable coding or reimbursement requirements
- Provide feedback to internal and external partners regarding level of care, length of stay, case outcomes, and clinical documentation
- Identify opportunities for clarification or additional medical-record documentation
- Apply relevant clinical and industry guidelines when reviewing cases
- Review cases using applicable utilization management and clinical documentation resources
- Use AI-enabled tools to support research, documentation review, workflow efficiency, and case analysis
- Research payer policies, contracts, and regulatory requirements
- Communicate with payers and clients regarding claim determinations and appeal rationale
- Maintain current knowledge of regulatory changes, clinical practice, payer requirements, healthcare technology, and industry standards
- Document findings and identify trends or information relevant to client needs
- Perform other related duties as assigned
- Work as an individual contributor without supervisory responsibilities
- Travel to home offices in Tennessee for training
Requirements
What you’ll need- Active RN or LPN license
- Clinical nursing experience
- Experience reviewing and interpreting medical records
- Familiarity with healthcare reimbursement, medical necessity, utilization management, denials and appeals, clinical documentation, or related functions
- Familiarity with ICD-10, DRG concepts, and electronic medical records
- Familiarity with AI-enabled tools or other healthcare technology used to support clinical, documentation, research, or administrative workflows
- Proficiency with common business applications, including Microsoft Word and Excel
- Experience in utilization review, case management, auditing, denials and appeals, CDI, or DRG clinical validation
- Familiarity with InterQual, MCG, CMS medical necessity requirements, and the Two-Midnight Rule
- Familiarity with CDI resources and guidance, including ACDIS and similar industry resources
- Experience with electronic medical record systems such as Epic, Cerner, or Meditech
- Experience using AI-enabled tools in clinical review, documentation, research, appeals, or related healthcare workflows
- Case management, coding, utilization review, or CDI certification
- Must already be authorized to work in the United States on a full-time, permanent basis without current or future sponsorship
- Must successfully pass a background check
Benefits
Comp & perks- Medical/Dental/Vision insurance
- 401K company match
- Flexible Paid Time Off
- Paid parental leave
- HSA/FSA options
- Educational reimbursement program
- Employer-paid EAP & Mental Health services