A Concurrent Review Nurse manages the inpatient and observes the treatment so as to determine if the patient has to stay in the hospital or to be discharged. The job duties listed on the Concurrent Review Nurse Resume are – reviewing medical records and assessing medical review standards, determining the overall health of the patient, and evaluating treatment needs, determining of the patient treatment is consistent with overall symptoms and diagnoses, creating a detailed patient status report and evaluating findings; developing treatment and discharge plans, collaborating with clinical staff, and identifying potential care management beneficiaries and providing referrals.
Sample resumes reflect a bachelor’s degree in nursing, and registered nurse licensure, and a post-baccalaureate certificate in fields such as case management or health care risk management. Apart from nursing skills, the individual should possess strong communication skills, and clinical and managed care experience.
Objective : Responsible for Referring to the guidelines to insure medical necessity is required and defer to the medical directors to either approve or deny admission or current stay in hospital, and also Documenting findings on the authorization form for the members of Health Plan of San Joaquin to either meet or not meet the guidelines.
Skills : Project Management, Planning Skills.
Description :
Designed and implemented QI/UM process for UCSF and SFHP organizations.
Negotiated and set up Fee For Service infrastructure.
Organized and charred QI committee.
Selected and implemented various provider relations and contracting protocols.
Negotiated rates with non-contracted facilities and healthcare providers including Title 22 ordinances.
Selected and implemented managed care guidelines.
Reviewed records for medical necessity and payment approval.
Experience
2-5 Years
Level
Executive
Education
Master Of Science
Concurrent Review Nurse Resume
Summary : A Concurrent Review Nurse with experience in various medical settings, seeking employment where I will be able to have my professional experience valued and utilized in a manner that will benefit both the company and me. I have extensive knowledge in computer programs including Microsoft Office and a quick study for computer programs overall.
Skills : Project Management, Communication Skills.
Description :
Evaluated severity of illness and intensity of service of members needs at time of admission utilizing approved criteria.
Developed and documented development of discharge planning within 24 hours of notification of admission.
Communicated to facility any pre-arranged discharge planning.
Demonstrated effective communication methods and skills, using lines of authority appropriately.
Established a relationship with providers in order to determine/provide needed services to member.
Acted as liaison and member advocate between the member/family, physician and facilities/agencies.
Maintained accurate record of concurrent activities.
Experience
7-10 Years
Level
Management
Education
MS
Concurrent Review Nurse Resume
Headline : Dynamic, multi-disciplined Concurrent Review Nurse Professional with diverse experience and proven record of accomplishment and leadership in clinical environments seeking a challenging and rewarding position with a progressive institution. Clinical expertise in Pediatrics, Emergency Room, Critical Care Concurrent Review, and Home Health with significant strengths in Business, Management, and Human Resources.
Skills : Member Of The American Nurses Association, Member Of The International Nurses Association, Member Of The Florida Nurses Association.
Description :
Utilized clinical skills to facilitate and coordinate services for Neighborhood Health members that were hospitalized in acute, skilled, and long term care settings.
Reviewed inpatient hospital admissions and assisted with the coordination of discharge planning needs.
Obtained the necessary information to assess member's clinical condition, identify ongoing clinical care needs and ensure that members receive services in the most optimal setting to effectively meet their needs.
Collaborated with physician and hospital personnel to facilitate and coordinate care needs across the continuum of care.
Performed concurrent and retrospective reviews on all inpatient, facility and appropriate home health services.
Monitored all utilization reports to assure compliance with reporting and turnaround times.
Addressed care issues with Director of Care Management and Chief Medical Officer/Medical Director as appropriate.
Experience
5-7 Years
Level
Junior
Education
MSN In Nursing
Concurrent Review Nurse Resume
Summary : Performing onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.
Skills : Nursing Skills, Planning Skills.
Description :
Monitored all inpatient care provided to members.
Evaluated and provided feedback to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered.
Coordinated an interdisciplinary approach to support continuity of care.
Identified covered services; including utilization management; transfer coordination.
Discharged planning; and issuance of all appropriate authorizations for covered services as needed for outside services for patients/families.
Consulted with physicians; health care providers; and outside agencies regarding care/treatment or hospitalization.
Identified and recommended opportunities for cost savings and improving the quality of care across the continuum.
Experience
7-10 Years
Level
Management
Education
MS
Concurrent Review Nurse Resume
Objective : Concurrent Review Nurse with 2 years of experience in Completing medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings.
Skills : Problem Solver With Strong Analytical, Detail Oriented, Ability To Multi-task, Excellent Communication Skills, Strong Clinical Assessment And Working Knowledge Of Various Software Applications.
Description :
Responsible for implementing and coordinating all utilization management functions relating to preauthorization of outpatient testing/surgery, and inpatient admissions for commercial plan members.
Assisted with the orientation of providers to the Plan's authorization and review procedures and work closely with participating physicians to secure information necessary for utilization management.
Assured the medical necessity and appropriateness of the delivery of healthcare resources provided to members as per their benefits package, through medical review of inpatient and outpatient service requests, utilizing established criteria, clinical judgment, and Medical Director guidelines.
Participated in the negotiation and notification processes that result from the medical record reviews with the facilities.
Prepared notification letters of denied and negotiated days within the established time frames.
Offered safe effective alternatives to the inpatient setting for those patients requiring interventions prior to their hospitalization.
Actively negotiated transitional levels of care when services requested do not meet acute care criteria.
Experience
2-5 Years
Level
Executive
Education
Diploma
Concurrent Review Nurse Resume
Headline : Dedicated and skilled nurse with a broad range of health care experience in direct services and management. Professional experience working in hospitals, clinics, social service agencies and health insurance companies. . Specialty areas in disease management, case management, geriatrics and psychiatry.
Skills : Nursing, IBM, Apple, Supervisor.
Description :
Utilized established criteria to authorize hospital admissions, diagnostic testing and ambulatory services etc.
Assisted in the identification and reporting of potential quality improvement issues.
Notified providers of coverage determinations in the appropriate manner and within the appropriate time frames.
Prompted attendance is required as employee works as part of a team & requires interaction with medical staff.
Adhered to quality standards and confidentiality policies and procedures.
Ensured compliance with all state and federal regulations and guidelines in day-to-day activities.
Adapted to changes in policies, procedures, new techniques and additional responsibilities.
Experience
5-7 Years
Level
Executive
Education
GED
Concurrent Review Nurse Resume
Headline : Concurrent Review Nurse Professional with extensive experience dealing with HPI, extensive computer skills, managing people and able to work well with staff and senior management. Several years of negotiating contracts for workers compensation organizations such as Liberty Mutual, Travelers, and Zenith through Healthcare Compare in the 1990s.
Reviewed charts from acute care facilities in SE portion of state of NM for and approve IP stay and services.
Appreciated getting to learn the job and work with many supportive and experienced nurses.
Learned how to extract clinical data for presentation for MD and the necessary procedures required for managing the members who have become hospitalized.
Improved Attention to detail, and professional responses in communicating with the facilities that Molina insures.
Mainly processed approvals and denials for Medicaid members who have many complex health issues who have been hospitalized.
Experienced presenting clinical data for brief presentations for the MD for patients who are not meeting IQ and communicate with the facilities and the CM or social worker for the best outcome for the Medicaid members.
Identified continuing care needs early in the inpatient stay to facilitate discharge to the appropriate setting.
Experience
5-7 Years
Level
Executive
Education
GED
Concurrent Review Nurse Resume
Summary : Organized, with proven leadership skills, within the healthcare industry. Over 25+ years of nursing experience, I have the managerial and customer service skills, with attention to detail, which is top priority. Posses experience working in a multidisciplinary team setting. Being a team player, who is able to excel in any position, I present with a strong background in management, home health, managed care, utilization management, and community health nursing.
Skills : Data Entry, Communication Skills.
Description :
Knowledged of Inter-Qual criteria as well as Milliman and Robertson Criteria's.
Completed 25-30 precerts daily.
Applied the criteria to the requested procedure for approval, utilizing the appropriate guidelines, as well as Aetna's proprietary software, submitted from the MD office.
Unable to approve, would refer to the medical director for determination.
Able to type 55-60 words per minute.
Observed excellent customer service skills at all times.
Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
Experience
10+ Years
Level
Senior
Education
BA
Concurrent Review Nurse Resume
Headline : To obtain a Concurrent Review Nurse position in the healthcare industry which will allow me to utilize my experience, training, and education in case management, utilization review, and nursing to assist people in meeting their health goals.
Skills : Microsoft Office, Cerner, 3M.
Description :
Responsible for Pre-admission, Admission & Concurrent Reviews using InterQual criteria for Managed Medicaid members transitioning or admitted to skilled nursing facilities, inpatient rehab facilities, and long term acute care hospitals.
Provided care management and discharge planning services working with the discharge planners & case managers and the post acute facilities to provide quality, cost effective care to members.
Prepared documentation for MD review.
Completed Level 2 assessments on referred cases to determine if the members would benefit from transitional care management as well as make referrals for follow up phone calls, complex care management & behavioral care management.
Reduced the number of inpatient days for several members by working with w/discharge planners & case managers to transition members to a lower level of care in a timely manner.
Reduced cost while maintaining the quality of care by working with facility discharge planners and case managers by transitioning members to alternate levels of care (ie transferring a vent weaning patient to a respiratory SNF instead of an LTACH for continued care).
Impacted & improved the quality of clinical orientation by identifying issues during y own orientation and bringing them to the attention of the manager 7 trainer.
Experience
5-7 Years
Level
Executive
Education
MS
Concurrent Review Nurse Resume
Summary : Over 16 years experience in the Neonatal Intensive Care setting seeking career transition utilizing knowledge of nursing and medical coding. Offer solid foundation in nursing care, chart review, computer skills, and database maintenance.
Skills : Case Management, Computer Skills, Wound Care, Meditech EMR, AHLTA DOD EMR, AllScripts EMR, Point Click Care EMR, Medication Administration.
Description :
Reviewed eligibility efforts for members IP at hospital requests for Medicaid members following NCQA guidelines.
Performed utilization reviews in accordance with state and federal regulations.
Attend meetings with medical staff to finalize patient discharge plans.
Approved members stay in the hospital for IP referrals.
Coordinated medical reviews for denial of IP stays.
Performed preadmission reviews for SNFS, LTACH, and Rehabs.
Utilized InterQual 2016.1 to assist IP requests for members from hospitals.
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