A Medical Review Nurse is a registered nurse who reviews a patient’s files and information and checks if proper care is being rendered. The job description entails going through recorded documents and determining if any type of improvement is necessary. Job duties associated with the post are described on the Medical Review Nurse Resume as – evaluating the patient’s current condition, assessing if the patient’s need extra stay at the hospital or can be discharged; providing recommendations to the doctor about their evaluation with the patient; reviewing medical claims and determining whether they are paid or not; reviewing patient’s present medical condition, and evaluating the patient’s situation against the hospital policies and insurance company’s standards.
As the job is stressful, the following skills are considered crucial for this role – the ability to deal with patients and patient’s relatives, doctors; and people from insurance companies; patience in dealing with a lot of people, knowledge of correct hospital procedures, and nursing administrative work, and multitasking skills. A person in this position is graduated with a bachelor of science in nursing and is a registered nurse.
Headline : To obtain a position as an LVN that will allow me to further my education in the medical field. Attending and actively participating with interdepartmental teams. Taking on special projects as requested by management. Demonstrating ability, under minimal direction to perform special projects, train new staff, analyzing inventory, revising current policies and procedures and or desk levels and develop and implement new policies and or desk levels.
Skills : Legan Nurse Consultant, Record Review, Chronologies, Summaries, Research.
Description :
Presented Administer medical review of incoming charts to identify need for additional medical information; as well as medical quality assurance (QA) on all charts in various process stages.
Assessed chart in association with physicians and other internal nursing staff members.
Served as the key resource of clients, the Medical Department, as well as the on-site provider.
Communicated with examinee through telephone or email to clarify information necessary to complete the chart, and follow through on requests for further evaluation from examinee when required.
Maintained comprehensive understanding of the specific contracts' guidelines and addendums as required; as well as of the codified state and federal regulations specific to particular contract(s).
Collaborated with other departments to provide accurate and quality outcomes.
Rendered support to interdepartmental project groups or task forces in integrating activities, coordinating issues, obtaining approvals, resolving problems, and maintaining specific level of knowledge pertaining to new developments, new task efforts, contract awards, and new policy requirements.
Experience
5-7 Years
Level
Executive
Education
Associate Of Applied Science
Medical Review Nurse Resume
Objective : Experienced telecommuter registered nurse reviewer seeking telecommute position in the field of nursing where my knowledge and skills will be fully utilized. Assisting in departmental training of new staff and ongoing in-services. Assisting in revising current policies and procedures and or desk levels, as needed and develops and assists in implementation of new policies and or desk levels.
Skills : Typing, MS Office, Phone , 10-Key, Documentation, Ledger Systems, Transcription, Venipuncture, Immunizations, Wound Care, Tracheotomy Care, G-Tube Care.
Description :
Medicare Part B Appeals Performed individual clinical reviews of medical records.
Identified medical necessity for claims.
Rendered medical decisions for claims.
Entered data electronically to process payments, denials and adjustments.
Followed confidentiality and security guidelines.
Maintained chain of custody on all documents.
Maintained internal quality control processes.
Experience
2-5 Years
Level
Executive
Education
Associate Of Applied Science
Medical Review Nurse Resume
Summary : Family Nurse Practitioner to provide health maintenance and for preventive healthcare for common medical problems. Clinical Internship CVS Minute Clinic Nashville, TN -Diagnosed and prescribed treatment to patients with minor illess. Performing physical examinations -Immunizations -EMR documentation Preceptor Judith Session, FNP Dr.attends courses offered by BCBSAZ Corporate Training and Development Department and the Medical Services Division; participating in appropriate computer-related educational offerings as relates to position function.
Skills : Attention To Detail, EMR, Microsoft Word, Excel, PowerPoint, Management , ICD-10, Citrix.
Description :
Completed appeals for the billing department by reviewing medical records for approval or denial of payment that has been appealed by the medical provider.
Participated in teleconferences.
Guaranteed workplace safety by maintaining compliance with corporate safety policy and participating in safety meetings and trainings.
Provided assistance in executing company initiatives to ensure compliance with Occupational Safety and Health Administration-Voluntary Protection Programs (OSHA VPP), International Organization for Standardization (ISO), Joint Commission on Accreditation of Healthcare Organizations (JCAHO), Accreditation Association for Ambulatory Health Care (AAAHC), and other regulations and standards.
Reviewed for additional payment when documentation supports that treatment above the usual care was provided during a procedure.
Reviewed were done in collaboration with the Bureau of Worker's Compensation of Ohio.
Used of Microsoft office applications include: Outlook, Office, and Excel.
Experience
7-10 Years
Level
Management
Education
Bachelors In Holistic Studies
Medical Review Nurse Resume
Summary : To obtain a secure Medical Review Nurse position within an organization that will allow me to utilize my acquired skills and knowledge for the growth and benefit of all customers. Creating and / or updating departmental Policies and Procedures. Participating in continuing education and current developments in fields of managed care.
Skills : Healthcare Management, Planning.
Description :
Checked given criteria (InterQual, NCD, LCD and EOC) for requested services from providers for medical necessity.
Kept a daily log of all activities (Approvals vs Denials).
Created Denial packets.
Supervised and direct the wordings of denial letters.
MT Identified and collected evidence and determined its value to a specific claims Completed required investigations on referred files in a timely manner.
Reviewed data to verify the validity of claims.
Effectively controlled the release of proprietary and confidential information for general client lists.
Experience
7-10 Years
Level
Management
Education
Bachelors Of Science In Nursing
Medical Review Nurse Resume
Headline : Professionally trained, accomplished, responsible and competent Registered Nurse, with excellent skills demonstrated by 44 years of experience, providing patient-focused nursing care to a diverse population and ensuring high standards of culturally competent care for a wide variety of patients with diverse needs.
Skills : Utilization Review, Training.
Description :
Applied comprehensive knowledge of medical terminology, anatomy & physiology, disease processes, treatment modalities, diagnostic tests, medications, procedures as well as the principles and practices of health services and the organizational structure to ensure proper code selection.
Prepared and conduct provider education on documentation processes in the health record to include the impact of documentation on coding, workload, quality measures, reimbursement, and funding.
Used a variety of computer applications in day to day activities and duties, such as Outlook, Excel, Word, and Access; competent in use of the health record applications (VistA and CPRS) as well as the encoder product suite.
Maintained statistical database(s) to track the results and validate the program for identifying patterns and variations in coding practices with regular reports to the medical staff and management.
Analyzed situations or processes and recommends improvements or changes in documentation as deemed necessary.
May assisted in writing coding protocol/policies which will reflect the required changes to enhance revenue through improved documentation.
Refered members for medical case management.
Experience
5-7 Years
Level
Executive
Education
BSN
Medical Review Nurse Resume
Headline : Medical Review Nurse with 5 years of experience in Utilizing quality tools in daily interactions and process improvements. Positively adapting to a changing work environment with flexibility and recognizes the impact the change will have on the appeal and grievance process. Adapting to changing work environment with flexibility and recognizes potential impact with ability to accentuate the positive to maintain/increase staff morale.
Skills : Managing, Interpersonal Skills.
Description :
Knowledged of coding and documentation concepts, guidelines, and clinical terminology.
Knowledged of anatomy and physiology, pathophysiology, and pharmacology in order to interpret and analyze all information in a patient's health record, including laboratory and other test results, to identify opportunities for more precise and/or complete documentation in the health record.
Collected and analyzed data and present results in various formats, which may include presenting reports to various organizational levels.
Established and maintained strong verbal and written communication with providers.
Knowledged of regulations that define healthcare documentation requirements, including The Joint Commission, CMS, and VA guidelines.
Extensive knowledged of coding rules and regulations to include current clinical classification systems (such as ICD, CPT, and HCPCS).
Knowledged of CPT Evaluation and Management (E/M) criteria to ensure the correct selection of E/M codes that match patient type, setting of service, and level of E/M service provided.
Experience
5-7 Years
Level
Executive
Education
BSN
Medical Review Nurse Resume
Objective : Medical Review Nurse with 4 years of experience in Making specific written recommendations to Manager with demonstrated ability to follow through on ideas. Accumulating and reporting statistics relative to inventory and timeliness. Submitting ad hoc reports as necessary. Identifying needs regarding enhancements to systems and/or processes. Actively participating on task force(s) as assigned and undertakes and completes special projects. Coordinating processing claims resolution with other departments.
Skills : Coordinating, Process Assistant.
Description :
Welcomed patients to our program/complete screening for AUD and determines if appropriate for the program as according to CIWA-AR screening.
Prompted the patient to download the Ria app and sign in to Zoom.
Educated patients on breathalyzer use and frequency.
Educated patients on Ria Health Medication Formulary and use of Anti-Craving medications, expectations/side effects.
Completed Initial Medical Intake and enters data into Ria Health EMR for clinicians to review.
Completed scheduling of First Medical Appointment.
Provided excellent medicare care and enjoy communicating with patients through video, messaging, and phone calls.
Experience
2-5 Years
Level
Executive
Education
MS
Medical Review Nurse Resume
Objective : Medical Review Nurse with 3 years of experience in Ensuring medically appropriate, high quality, cost effective care through assessing the medical necessity of inpatient admissions, outpatient services, focused surgical and diagnostic procedures, out of network services, and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards accurately interpreting benefits and managed care products and steering members to appropriate providers, programs or community resources.
Skills : Community Assistant, Treatment Planning.
Description :
Joined a team of Mission driven professionals dedicated to offering a next-generation solution in the treatment of heavy alcohol use and addiction.
Experienced professional growth within a rapidly expanding tech-healthcare company.
Worked remotely anywhere in the United States.
Know ledged of training methods and teaching skills sufficient to conduct continuing education for staff development. The training sessions may be technical in nature or may focus on teaching techniques for the improvement of clinical documentation issues.
Collaborated with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
Worked with medical directors in interpreting appropriateness of care and accurate claims payment.
May also managed appeals for services denied.
Experience
2-5 Years
Level
Executive
Education
G.E.D
Medical Review Nurse Resume
Objective : Medical Review Nurse with 2 years of experience in Maintaining knowledge of activities in assigned area and possesses the ability to provide assistance as necessary. Maintaining current knowledge of department policies, medical policy guidelines, benefit plans and utilization criteria for all local lines of business as it relates to the processing of Medical Review claims. Analyzing and monitoring claims for trends. These trends may illustrate an educational need; need for a referral to a different BCBSAZ department; need for updating a policy / guideline.
Skills : Review Nurse, Analyzing Skills.
Description :
Conducted pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Ensured member access to medical necessary, quality healthcare in a cost effective setting according to contract.
Consulted with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process.
Collaborated with providers to assess member’s needs for early identification of and proactive planning for discharge planning.
Facilitated member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications.
Facilitated accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Composed correspondence, reports and referral summary letters.
Experience
2-5 Years
Level
Executive
Education
MS
Medical Review Nurse Resume
Objective : To obtain a Medical Review Nurse is Assuming responsibility for in-depth analysis and final resolution of claims requiring clinical review according to department policy, BCBSAZ, State, Federal requirements, as applicable. This may involving coordinating with other BCBSAZ departments. Maintaining effective communication (verbal and written), both formal and informal with internal and external customers.
Communicated effectively, internally and externally.
Handled confidential material.
Reported work activity on a timely basis.
Worked independently and as a member of a team to deliver high quality work.
Attended meetings, training, and conferences, overnight travel required.
Maintained productivity and accuracy requirements set for this level.
Demonstrated ability to complete all types of reviews utilizing, but not limited to: appropriate benefit plans, policies, guidelines, claims processing system, member enrollment, provider contracts, BCBSAZ communication records and precertification system.
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