Utilization Review Nurse Resume Samples

Description :

1. Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
2. Appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits.
3. Managed care products, and steering members to appropriate providers, programs or community resources.
4. Applies clinical knowledge to work with facilities and providers for care coordination.
5. Works with medical directors in interpreting appropriateness of care and accurate claims payment.
6. Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria.
7. Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
8. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process.

Experience

7-10 Years

Level

Management

Education

BSN

Description :

1. Authorizing cases according to approved criteria across the continuum of care to ensure a positive patient outcome.
2. Directly responsible for reviewing pre-certification requests, performing inpatient and outpatient reviews, and obtaining, reviewing.
3. Maintain knowledge of policy and procedure manual for medical/behavioral health services requiring certification including.
4. Apply excellent ability to determine the medical necessity and appropriateness of care using established criteria.
5. Refer potential high-risk cases which will benefit from case management services to the case management team.
6. Charged with assessing the social, economic, environmental, and emotional factors that interfere with patient and family adjustment to illness and treatment.
7. Interface with multidisciplinary staff to identify social factors impacting member illness and treatment.
8. Identify and obtain needed community resources and provide feedback to external agencies on cases as necessary.

Experience

5-7 Years

Level

Executive

Education

Diploma

Description :

1. Perform review activities for procedures that require preauthorization and Issue approvals for studies that meet specified guidelines. 
2. Documents appropriate clinical information into the prior authorization system.
3. Participates in on-going training programs to ensure quality performance and compliance with guidelines.
4. Maintains a safe, comfortable and therapeutic environment for patients and families in accordance with hospital standard.
5. Promotes a positive work environment as evidenced by Demonstrating a professional, supportive attitude for the unit staff, Being receptive and responsive to new ideas.
6. Participates in the unit's continuous quality improvement plan to improve organizational performance.
7. Maintains established departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards.
8. Assists in cost containment through the appropriate ordering and conserving of supplies and equipment.

Experience

0-2 Years

Level

Entry Level

Education

BS

Description :

1. Collected in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, learning needs, and financial constraints.
2. Conducted an on-going assessment of the case and discharge an individual from case management services when the optimum status has been achieved.
3. Screens for cases which do not meet the client-specific guidelines, i.e.  Physician-developed criteria, guidelines and refers them to the Medical Panel accordingly.
4. Establishes a quality check date using client-specific guidelines.
5. Utilizes nursing experience and judgment in addition to the client-specific guidelines when determining medical necessity and quality check dates.
6. Performs accurate and complete verification of eligibility, benefits, and coverage and apply this information to the pre-certification.
7. Performed continuous review of claim trends and issues to identify additional provider/patient education needs.

Experience

5-7 Years

Level

Executive

Education

Associates

Description :

1. Responsible for referring to complex clinical and medical procedure request to the medical director for review.
2. Maintained confidentially and compliance adhering to Health Insurance Portability and Accountability Act (HIPPA) guidelines when reviewing medical documentation.
3. Requesting clinical information, or providing Utilization Review determinations in written or verbal format.
4. Worked independently processing preauthorization request by utilizing critical thinking skills, excellent communications skills, leadership skills, and organizational skills.
5. Proficiently established positive and effective work relationships with co-workers, adjustors, providers, and nonmedical staff.
6. Met and exceed accuracy and quality standards efficiently multitasking and triaging caseload.
7. Process and review clinical documentation for the purpose of utilization review and precertification/preauthorization determinations.

Experience

10+ Years

Level

Senior

Education

Diploma

Description :

1. Identify, monitor and evaluate concurrent care of all hospitalized enrollees.
2. When appropriate, recommend alternatives to traditional health care to medical directors, network physicians, or non-participating physicians.
3. Identify the primary care nurse in the hospital and monitored critical pathways, as applicable.
4. Provide and maintain an open system of communication and feedback between the enrollee, hospital, and other levels of care in the community.
5. Included information with payor and providers to ensure continuity and efficiency of care.
6. Participate in or initiate conferences with the physician, social worker, and other relevant health care team members regarding post-hospital care of patients.
7. Track patient progress and care received to identify deviations from accepted care standards.
8. Coordinate coverage for rental or purchase of durable medical equipment and records details of these interactions and approve claims for payment.

Experience

2-5 Years

Level

Junior

Education

Associate

Description :

1. Coordinated mental health services with clinics, specialized units, affiliated private agencies, and available community resources.
2. Participated in the development of policies, standards, and guidelines to oversee the performance of agencies contracted to provide mental health treatment statewide.
3. Provided project management and participated in onsite clinical record audits to determine contract compliance.
4. Compiled data, developed statistical analyses and prepared reports for monitoring in-network private physicians' offices and treatment clinics.
5. Responsible for sensitive investigations related to reported incidents and/or complaints initiated by and personal requests from state officials.
6. Completed full investigations by reporting findings to the appropriate state, city, or regulatory agencies.
7. Concluded investigations by sending personal correspondence to the initiator of complaint or incident indicating what findings could be released.

Experience

5-7 Years

Level

Executive

Education

BS

Description :

1. Promotes and restores patient health by identifying patient care requirements.
2. Makes recommendations, documents findings and collaborates with physicians and multidisciplinary team members to provide physical and psychological support.
3. Review medical records to determine medical necessity based upon pre-determined Milliman Criteria.
4. Discharge Planning and/or Concurrent Obtain member's medical records and work with providers in order to facilitate a safe discharge plan.
5. Evaluate requested outpatient services for medical necessity and setting, search for appropriate participating providers and negotiate rates.
6. Perform concurrent reviews of clinical information to determine if the member is receiving appropriate care in the most appropriate setting.
7. Adhere to standards of care in order to meet governing agency regulations and assure the patients quality of care.

Experience

2-5 Years

Level

Junior

Education

Associate

Description :

1. Performs concurrent review of clinical information to determine appropriateness and medical necessity of hospitalization and treatments using Interqual criteria.
2. Evaluate the progress of each patient daily and provide updates to insurance providers.
3. Follow patients from admission to discharge, ensuring the current level of care is optimal.
4. Communicate necessary moves from acute care to a lower level of care at appropriate intervals.
5. Collaborate with other professionals to evaluate patients' medical or physical condition and to assess client needs for safe discharge.
6. Collaborate with Nurse Navigators to identify frequent hospital readmissions.
7. Serve as liaison between patients, families, and health care providers.
8. Plan discharge from care facility to home or another care facility.
9. Coordinate home care, home hospice, and DME services post-hospital discharge.

Experience

10+ Years

Level

Senior

Education

BSN

Description :

1. Review requested medical treatment for medical necessity and medical appropriateness and provide prior authorization for requested treatment.
2. Perform reviews of current patient services, and determine medical appropriateness of patient services following evaluation of medical guidelines.
3. Make decisions and exercise good judgment in a complex environment.
4. Provide telephonic case management of Workers' Compensation claims by facilitating and coordinating all aspects of the injured worker's medical care.
5. Maintain a high standard of file documentation to ensure attention to detail and file accuracy.
6. Interact with strategic partners to obtain or clarify clinical information.
7. Compare clinical information against the appropriate criteria set.
8. Authorize medical care and practice medical costs containment skill using the utilization review process.

Experience

7-10 Years

Level

Management

Education

BS

Description :

1. Performs concurrent and retrospective review to establish criteria.
2. Exercises clinical judgment and objective application Severity of Illness/Intensity of Service criteria in assessing patient medical condition.
3. Clinical knowledge of referring to appropriate departments for Children's Special Health Care eligibility.
4. Writing, submitting according to departmental policies timely Denials, Dis-enrollments, and referrals to Case Management.
5. Assists hospital staff in identifying post-acute care needs in accordance with product insurance benefit availability.
6. Evaluation of medical documentation and requesting additional information for transplant eligibility to present to the medical director.
7. Processing referral requests for DME, Infusions, Home Health Care, Wound Vacuum's, Subacute Rehabilitation, Inpatient Psych, and Inpatient Rehabilitation.
8. Notification to the medical director of all high-cost hospital stays for re-insurance group tracking.

Experience

10+ Years

Level

Senior

Education

Nursing

Description :

1. Served as the liaison between patients, doctors, healthcare providers, and insurance companies.
2. In contrast to direct patient care at the bedside, my role was to advocate for all patients enrolled in the healthcare delivery system.
3. Worked with a diverse group of patients including the elderly and those who participate in government programs.
4. Accountable for Utilization and Quality Management of examination levels, technology, and medication use efficiency, while simultaneously improving patient outcomes.
5. Managing expenses and improving the quality of life for persons with long-term conditions.
6. Performed a continuous review of claim trends and issues to identify additional provider/patient education needs.
7. Reviewed claims for the severity of illness and necessity of service; request supplemental information as needed to finalize claim determination.

Experience

10+ Years

Level

Senior

Education

MS

Description :

1. Responsible for reviewing precertification requests for medical necessity.
2. Responsible for obtaining and reviewing daily clinical information for concurrent review, extending the length of stay as medically necessary.
3. Responsible for coordinating care to promote improved quality of life and prevent hospitalization.
4. Accountable for overseeing a group of nurses in conducting daily task which includes prioritization of authorization notification to providers and case managers.
5. Assisting nurses with identified issues by addressing, assessing and analyzing these issues to find a resolution.
6. Involved in overseeing and coordinating utilization management ques to meet established performance metrics.
7. Performing utilization and concurrent reviews using Milliman criteria while auditing the quality performance of practitioners and facilities.

Experience

10+ Years

Level

Senior

Education

BS

Description :

1. Proactively involved in all aspects of Utilization Management including precertification, concurrent review, discharge planning, and clinical case appeals.
2. Ensure patient admissions are in compliance with Medicare by using Milliman Care Guidelines.
3. Review electronic and paper charts to provide documentation for admission/ stay criteria.
4. Confer with internal and external physicians to assess the appropriateness of the level of care.
5. Analyze appropriate data to identify trends/problems relating to delays in the delivery of care and patient placement.
6. Initiate timely communication with insurance companies to obtain authorization for hospitalizations and advanced imaging to achieve the maximum allowable reimbursement.
7. Notify third-party payors, including various state Medicaid programs, via online websites.

Experience

10+ Years

Level

Senior

Education

Diploma