A Utilization Review Manager works for the insurance industry and analyses health care needs in medical cases and determines further patient care. The job duties include conducting interviews to determine what services to register for and cutting down unnecessary costs. Other accountabilities are mentioned on the Utilization Review Manager Resume as – leading and directing the utilization review staff at a health care facility, determining procedures and policies that best ensure effective utilization, monitoring reviews to ensure patients receive care, preparing analysis and reports on significant utilization trends, reviewing medical records to help improve patient care; and conducting interviews to determine the patient’s current required services.
Required skills and abilities include – excellent verbal and written communication skills, excellent organizational skills, attention to detail, proficiency with MS Office Suite or related software; and experience with utilization review. Most resumes reflect a bachelor’s degree in nursing, as well as registered nurse licensure and certification in case management.
Headline : Utilization Review Manager is responsible for providing information to members regarding mental health and substance abuse benefits, community treatment resources, mental health managed care programs, Interacting with Physician Advisers to discuss clinical, authorization questions and concerns regarding specific cases, Participating in QI activities, including data collection, tracking, and analysis.
Skills : Ms Word, Management Experience, Quality Assurance, Training, Consulting.
Description :
Managed a staff of three Utilization review Clinicians.
Oversaw the utilization review of a 120 bed psychiatric hospital.
Oversaw the utilization review of the outpatient programs; PHP, IOP, and CDIOP.
Oversaw the assignment of denials.
Trained all new Utilization Review Clinicians.
Wrote appeals to payers to recover denied funds.
Assigned all patients to the Utilization review Clinicians.
Experience
5-7 Years
Level
Executive
Education
Masters In Social Work
Utilization Review Manager Resume
Summary : Have 18 years experience in the mental health field, including geriatrics, residential, crisis, utilization review and administrative work. Strong points are coordination of care and resource management.
Skills : Navinet, Exel, Microsoft Word.
Description :
Presented Verify all insurances, claims addresses and copays prior to admission to the program.
Obtained initial authorization for Intensive outpatient services and partial hospital program.
Coordinated with all clinical staff for continuation of services and perform concurrent review.
Communicated with psychiatrist patient concerns.
Acted as a liaison between client and insurance companies.
Assisted Psychiatrist in obtaining Prior authorization of medications.
Called in medications for clients when appropriate.
Experience
7-10 Years
Level
Management
Education
MS
Utilization Review Manager Resume
Summary : Have 14 plus years of inpatient hospital case management experience in an LTACH (long term acute care hospital) setting as the case manager; and Director of the Case Management Department working with patients, families, and physicians to have medically necessary hospital stays with safe and appropriate discharges; and achieving for the hospital a strong financial outcome and profit.
Skills : Detail Oriented, Customer Service, Communication, Computer Literate, Microsoft Office, Interqual Criteria, Milliman And Roberts Criteria Sets, HMS, Western LOS Criteria.
Description :
Managed staff of 12 to 20 employees including RN staff in the review of all hospitalized members for inpatient stays for admission and concurrent review.
Supervised the review process for all outpatient authorizations assisting staff with the decision-making process.
Reviewed and approved/denied all out-of-network services.
Reviewed claims for medical necessity and failure to obtain authorization.
Assisted review RNs with appeals, making recommendations to the Medical Director for final approval or denial.
Assisted the Director of UR with the creation of all policies and procedures for the Utilization Management Department.
Worked closely with claims manager to assure prompt payment of authorized services and provide a quick review of appeals, and non-authorized services.
Experience
10+ Years
Level
Senior
Education
High School Diploma
Utilization Review Manager Resume
Headline : Motivated, tenacious, ambitious, hard-working professional exploring possibilities of a new challenging career with a great organization. I am looking to become an addition to a professional environment that will allow me to utilize my wide array of talents and expertise as well as add to my skill base. I am confident enough to know that if given the opportunity I will achieve and produce successfully at optimal standards.
Skills : Microsoft Office, Asana, Taleo, Peoplesoft.
Description :
Performed initial, continuing and retrospective reviews of mental health information based on company-selected behavioral health Utilization Review Guidelines.
Reviewed patient health information and evaluates patient progress.
Obtained and reviewed necessary medical/mental health reports and treatment plans as needed to conduct utilization review functions.
Reviewed and validated physician's orders, clinical progress reports, and unusual occurrences involving patients.
Documented review information into Interqual system according to established procedures in an efficient and timely manner correctly reflecting medical record information received.
Received and processed requests for appeals and maintains required tracking systems.
Responded to complaints per Utilization Review Guidelines.
Experience
5-7 Years
Level
Executive
Education
Bachelor Of Arts
Utilization Review Manager Resume
Summary : Versatile and results-oriented administrative assistant seeking a position that will utilize my ability to manage and complete multiple tasks accurately and by a deadline. I am a highly motivated self-starter who is fully committed to proving myself in a new field.
Skills : Developing Skills, Revenue Management.
Description :
Reviewed/audited using InterQual screening criteria to determine the correct level of care and interventions used to prove medical necessity.
Recorded for the hospital and faxed or phoned to the various payors to assure them of the patient's treatment and need for medical care.
Prevented revenue loss by defining areas that needed additional notifications to the insurance or Medicaid payors.
Relayed to the department's management team that BJH was the nearest triage center for high-risk mother-baby patients for Southern Illinois and that we were an out-of-network provider without a contract.
Remedied to provide the needed care for our patients and correct reimbursement for the facility.
Developed a spreadsheet to log the transfer of sick neonates to St Louis Children's and the transfer back to BJH's lower level III nursery for clarity in billing and patient medical record accuracy.
Assisted with building an EMR and with tailoring a Referral website called ECIN by Allscripts to the needs of Case Management and Utilization review.
Experience
10+ Years
Level
Senior
Education
Master's
Utilization Review Manager Resume
Summary : Utilization Review Manager looking for an opportunity to advance my professional skills with new areas of knowledge. I am a self-starter, organized, multi-tasking hard worker with many years of experience in various areas of the nursing profession, specializing in the psychiatric discipline.
Skills : Operating Skills, Machine Management.
Description :
Responsible for all stay submissions to both Medicaid and private insurance companies.
Managed the nursing portion of the master treatment plan and all reviews.
Reviewed submitted medical and psychiatric information for referrals to help determine suitability for the program.
Communicated with all disciplines in the facility as well as corporate referral sources.
Managed all utilization review processes and staff.
Charged Nurse, Piney Ridge Treatment Center Responsible for supervising multiple units in a fast-paced environment for adjudicated sex offenders with dual diagnoses, as well as supervising and training other RNs and LPNs, staff supervisors, and youth care workers on both day and night shifts.
Compiled a self-help guide to train other nurses in managing this specialty in utilization review.
Experience
10+ Years
Level
Senior
Education
High School Diploma
Utilization Review Manager Resume
Headline : A driven Utilization Review Manager seeking a position that will utilize leadership, lean training, process improvement knowledge, utilization review knowledge, and case management experience and skills.
Skills : Lean Six Sigma Training, Collaborative Skills.
Description :
Responsible for assessing the level of care based on the medical necessity with use Interqual.
Reviewed observation admissions for charge entry.
Provided staff and physician education about the level of care.
Collaborated with third-party payors for optimal reimbursement.
Changed status as necessary based on reviewed level of care.
Responsible for Medicare short stay and observation audits provided to BJC corporate.
Used I have to utilize my maternal child background to justify the severity of illness and intensity of services required by these patients.
Experience
5-7 Years
Level
Executive
Education
Masters Of Science
Utilization Review Manager Resume
Headline : Executive-level Utilization Review Manager with expertise in healthcare consulting, administration, and nursing reflecting the insight to assess needs, devise forward-thinking solutions, and facilitate change by guiding multiple stakeholders to progress toward a unified vision focused on optimizing operational effectiveness of hospitals and medical systems.
Skills : Microsoft Office Suite, System Management.
Description :
Acted as a liaison between commercial insurance organizations and facility clinical and medical staff.
Conducted clinical/medical reviews in accordance with certification requirements of each client's insurance plan.
Made required phone and/or written contacts with insurance organizations to obtain necessary certifications and continuing care referrals.
Kept accurate records of all contacts with external organizations/ persons such as insurance companies, referrals, and family members.
Adequately informed clinical and medical staff of any specific concerns that would extend or restrict a client's length of stay by the various managed care standards.
Worked collaboratively with coworkers and clinical staff to secure the best possible services and length of stay for each client.
Maintained and communicated knowledge of the clinical programs offered through the White Deer Run System to insurance companies and consumers.
Experience
5-7 Years
Level
Executive
Education
Bachelor's Of Arts In Psychology
Utilization Review Manager Resume
Summary : Have 12 years of experience in all levels of utilization management with a full and comprehensive understanding of the regulations and requirements per state. I have also developed a large network of physician reviewers for recruiting purposes.
Skills : Reviewing, MS Office, Auditing.
Description :
Directed daily tracking and accurate reporting of authorization status on LOC patient authorizations, peer-to-peer reviews for doctors and insurance companies.
Maintained daily status reports related to UR authorizations.
Provided precertification staff with support and executive staff with UR authorization reports.
Prepared accurate monthly cost savings reports.
Facilitated comprehensive training of all clinicians on MCO Medical Necessity guidelines and developed a training manual for UR processes and procedures.
Led audits of charts for higher medical risks and EMR clinical information for deficiencies to ensure optimal quality of care.
Consistently maintained completed UR compliance with federal, state, and local regulations.
Experience
7-10 Years
Level
Management
Education
Bachelor Of Science
Utilization Review Manager Resume
Summary : Highly motivated individual seeking a senior level management position in Contracting, Administration, Mental Health, Juvenile Justice, Policy Planning and/or Quality Improvement. Have over 20 years of professional experience in the assessment, monitoring, contracting and development of programs in social service, juvenile justice, mental health, and, patient advocacy.
Skills : Monitoring Skills, Medical Skills, Insurance Care.
Description :
Managed clinical reviews for commercial insurance companies for clients in the care of White Deer Run - Allenwood.
Contacted insurance care managers to update client progress and secure funding for length of stay.
Worked independently on assigned work tasks.
Communicated with all departments to ensure proper dissemination of clinical information.
Maintained strict confidentiality standards Excellent written and verbal communication skills with facility staff and insurance care managers.
Provided ongoing support and training for clinical/medical staff on documentation strategies, stay criteria, and meeting specified requirements for various payers.
Prepared information for notification letters for MHM clinicians and as necessary TDOC Mental Health Staff.
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