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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in conducting prior authorization reviews and applying clinical guidelines while ensuring compliance with health plan guidelines and medical necessity criteria. Proficient in collaborating with healthcare professionals to facilitate seamless care transitions and enhance communication within the post-acute care environment.
Highest-signal resume keywords
Utilization ReviewClinical Guidelines ApplicationActive RN, OT, or PT LicenseMCG Guidelines ExperienceCase Management Collaboration
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 Nursing ExperienceTherapy ExperienceBenefit DeterminationCare CoordinationCompliance with Accreditation Standards
Soft Skills
CollaborationCommunicationProfessional Growth
Tools & Technologies
InterQualClinical Decision Support Tools
Certifications & Qualifications
Bachelor's DegreeActive RN LicenseActive OT LicenseActive PT License
Industry Keywords
Post-Acute CareManaged Care RegulationsHealth Plan GuidelinesFederal and State Compliance
About the role
Key responsibilities & impact- Conduct prior authorization reviews and/or continued stay reviews for post-acute care services by applying clinical guidelines and escalating cases to medical directors as needed
- Approve services in compliance with health plan guidelines, contractual agreements, and medical necessity criteria
- Collaborate with case managers, physicians, and medical directors to ensure appropriate levels of care and seamless care transitions
- Participate in team meetings, educational activities, and interrater reliability testing to maintain review consistency and professional growth
- Ensure compliance with federal, state, and accreditation standards, and identify opportunities to enhance communication or processes
- Support all payer programs and initiatives related to the post-acute space
- Make benefit determinations about appropriate levels of care using clinical guidelines
- Coordinate benefits and transitions between various areas of care
- Utilize knowledge of resources available in the healthcare system to assist physicians and patients effectively
- Perform other job duties as assigned
Requirements
What you’ll need- Bachelor's degree or equivalent work experience
- 4-6 years of clinical nursing or therapy experience
- Active RN, OT, or PT license
- 1-2 years' experience in utilization review, case management and/or managed care regulations (preferred)
- Experience with MCG Guidelines, InterQual or other clinical decision support tools, especially in utilization management and prior authorization processes (preferred)
Benefits
Comp & perks- Excellent medical with Rx, dental, and vision benefits
- Mental Health support through EAP
- Generous paid time off, plus 13 paid holidays
- 100% vested 401(K) retirement plans
- Educational assistance up to $2500 per year