Utilization Review Nurse Resume Samples

The primary responsibility of a Utilization Review Nurse is to review the patient case and make sure that the patients are getting the appropriate treatments. The duties listed on the Utilization Review Nurse Resume are – evaluating present condition of the patient, assessing the patient status, verifying the health care costs and policies are adhered to properly, referring patient case to appropriate Doctor, reviewing the insurance policy of the patient, getting the approval of the Doctor before starting a treatment plan.

Utilization Review Nurses need a certain amount of skills and qualifications to reach this post, and such include – patience to deal with distressing and difficult patients, good knowledge about medical claims and insurance claims, knowledge of hospital procedures and nursing administration; and patient case management experience. Apart from having a nursing degree and registered nurse licensure, these nurses should have a post-Baccalaureate certificate in healthcare risk management or case management.

Utilization Review Nurse Resume

Summary : Dedicated registered nurse (RN) with specialty experience in cardiac/medical surgical nursing. Developed a strong knowledge of cardiac nursing. Reliable, an ethical healthcare provider with the ability to stay calm and intervene during crises, and to collaborate on multidisciplinary teams.

Skills : Medicare, Utilization Review, Prior Authorization, Emergency Room Nursing, Air and Ground Transport Nursing, BLS CPR, Critical Care Nursing, Flight Nursing.

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.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
BSN


Utilization Review Nurse-RN Resume

Headline : Proven record of reliability and responsibility. Strong analytical skills, capable of assessing conditions and implementing appropriate intervention. Resourceful problem solver capable of implementing solutions to complex problems. Relate well to people from a variety of cultures.

Skills : Medical Front Office, Microsoft Office, Excellent Organizational Skills, Excellent Interpersonal Communication Skills.

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.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
Diploma


Utilization Review Nurse I Resume

Objective : Caring Registered Nurse with excellent communication skills with over one year of experience in adult and geriatric care in an acute hospital and dialysis setting. Possess special sensitivity to meeting diverse needs in varied situations.

Skills : Word, Excel, Powerpoint, Strong Analytical Skills, Communication Skills, Medical Terminology.

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.
Years of Experience
Experience
0-2 Years
Experience Level
Level
Entry Level
Education
Education
BS

Utilization Review Nurse-Case Manager Resume

Headline : Experienced RN in areas such as ER, ICU, Ambulance transport, Flight Nursing, Occupational Health, Case Management, Utilization Review for private and Medicare insurance plans. Open to new opportunities and roles.

Skills : Interqual, Milliman, Microsoft office suite, Facets, CMS guidelines, Time management, Remote working environment, Attention to detail and cost containment, Biographical timeline development, Root Cause Analysis.

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.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
Associates

Utilization Review Nurse II Resume

Summary : Motivated, professional with 10+ years of track record in the medical field as a Utilization Review Nurse is now seeking to obtain a full-time Care Review Clinician UR LPN position.

Skills : Utilization Review, Case Management, Customer Service, Nursing.

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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Diploma

Utilization Review Nurse-Temp Resume

Objective : Dedicated healthcare professional, known as a natural leader and change agent, who has designed career experiences and education to develop a broad understanding of our highly integrated and complex healthcare system.

Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint.

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.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Junior
Education
Education
Associate

Jr. Utilization Review Nurse Resume

Headline : Seeking to work with a company that offers high standards of care for patients. Placing the patients needs first. To be part of a team to develop business by building relationships with physicians, case managers, social workers, and discharge planners.

Skills : BLS, Group Management, Reliability, Decision-Making Skills.

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.
Years of Experience
Experience
5-7 Years
Experience Level
Level
Executive
Education
Education
BS

Utilization Review Nurse II Resume

Objective : 3 years as a Registered Nurse with experience in the clinical setting, case management, care transitions, and utilization review. Having management experience in sub-prime lending, consistently recognized as a top performer.

Skills : Managed Care, Nursing, Marketing, Wound Care.

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.
Years of Experience
Experience
2-5 Years
Experience Level
Level
Junior
Education
Education
Associate

Utilization Review Nurse-Clinical Resume

Summary : 32+ years of vast experience in core measures concurrent review/utilization management as a Clinical Data Coordinator for the Performance Improvement. Selected to pilot an RN Telecommute program to perform utilization review/concurrent review remotely after proving my dedication, self-motivation, and reliability.

Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
BSN

Utilization Review Nurse-Part Time Resume

Summary : Utilization Review Nurse with the knowledge and ability to apply various care guidelines while working with physician advisor's to complete reviews within set time frames. Able to work in a fast-paced environment to meet the needs of clients

Skills : Utilization Review, Case Management, Excellent Organizational Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

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.
Years of Experience
Experience
7-10 Years
Experience Level
Level
Management
Education
Education
BS

Utilization Review Nurse-URN Resume

Summary : Energetic, talented, and accomplished Licensed Practical Nurse experience working as LPN and Medical Secretary. Extensive background working with medical records and computer-based scheduling systems. Able to work well in interdisciplinary team environments, coordinating with physicians, and other healthcare staff.

Skills : Strong Clinical Reasoning, Medical Records Review, Excellent Organizational Skills, Excellent Interpersonal Communication Skills.

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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Nursing

Utilization Review Nurse-LPN Resume

Summary : Excels in relationship building, presentation skills, and psychiatric mental health clinical nursing. Strong background in psychiatric mental health clinician, education and management Motivated, an organized candidate who is able who work well with others in a fast-paced, team-oriented environment.

Skills : Utilization Review, Case Management, Customer Service, 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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
MS

Associate Utilization Review Nurse Resume

Summary : An individual with 11 plus years of experience as a Utilization Review Nurse, two years as supervisor of the concurrent review team. Over ten years of experience as a staff nurse and supervisor in a sub-acute and long-term setting.

Skills : Professional Services, Customer Relationship Management, Case Management, Pediatric Experience, Adult experience.

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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
BS

Utilization Review Nurse Resume

Summary : Instructions and work related to Nursing wherein one can use background, theoretical knowledge, actual skills, and attitude to provide quality, safe, and effective care, to help achieve goals and objectives of the company, and to be globally competitive.

Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

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.
Years of Experience
Experience
10+ Years
Experience Level
Level
Senior
Education
Education
Diploma