Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

GENERAL SKILLS EXPERIENCE *
Familiar with Milliman guidelines123
Familiar with InterQual criteria and computer software123
Familiar with Medicare guidelines123
National Patient Safety Goals123
Patient/family teaching & education123
Awareness of HCAHPS123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

REGULATING AGENCIES *
CMS: Centers for Medicare & Medicaid Services123
OSHA: Occupational Safety & Health Agency123
Department of Health123
The Joint Commission123
HIPAA: Health Insurance Portability & Accountability Act123
Disability management123
Worker’s compensation123
Data abstraction123
Discharge planning123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

ASSESSMENT EXPERIENCE *
Assesses resource utilization123
Cost management123
Diagnosis123
Past/present treatment course & services123
Prognosis123
Goals123
Treatment & provider options123
Prior authorization reviews123
Continued stay reviews123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

PLANNING EXPERIENCE *
Collaboration with client/family & members of the healthcare team123
Identification of immediate, short-term & ongoing needs123
Develops appropriate and necessary case management strategies123
Discharge planning123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

EVALUATION EXPERIENCE *
Pre-certification review123
Concurrent utilization review123
Retrospective utilization review123
Benefits eligibility review123
Drug utilization review123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

WORK SETTING EXPERIENCE *
Hospital123
Occupational health123
Insurance company123
Health maintenance organization review department123
HMO utilization review call center123
Home health123
Hospice123
Managed care service provider123
Long-term care123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

SOFTWARE PROGRAMS EXPERIENCE *
MeDecision123
TILE123
OASIS123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

INPATIENT BASED SKILLS EXPERIENCE *
Universal precautions123
Cardiac arrest/CPR123
Use of rapid response teams123

Rank each of the following sections on a scale of 1 to 3:
1) Limited or no experience
2) Experienced, but may need review or supervision
3) Able to function independently

AGE SPECIFIC COMPETENCIES EXPERIENCE *
Newborn / neonate (birth-30 days)123
Infant (31 days-1 year)123
Toddler (ages 2-3 years)123
Preschool (ages 4-5 years)123
School age (ages 6-12 years)123
Adolescent (ages 13-21 years)123
Young adult (ages 22-39 years)123
Adult (ages 40-64 years)123
Older adult (ages 65-79 years)123
Elderly (ages 80+ years)123
ATTESTATION *