Utilization Review Specialist Resume
Summary : Motivated, personable nursing health care director professional with multiple college degrees and a successful 10-year track record of providing quality patient care.
Skills : Technical Skills, Analysis.
- Offered immunizations, shots, general exams, health education materials, and over the counter medication as needed.
- Assisted in company health/wellness examination programs.
- Orderedpatient appropriate DME equipment as needed Arrange home health, IV antibiotics and Wound vacs as needed.
- Assisted employee health nurse with duties as assigned as needed.
- Responsible for all hospital readmission assessments of patients readmitted with thin 3o days.
- Helped the patient/families navigate through possible barriers to care.
- Ensured the patient is able to get medical access and referral resources in an efficient and expedited manner.
Utilization Review Specialist/Representative Resume
Summary : To obtain a challenging position in the medical field where can utilize skills and also be a learning experience at a great company.
Skills : Problem Solving Skills, Analytical Skills.
- Ensured compliance and accuracy while identifying actions in need of reviews.
- Completed admissions reviews, stay reviews, and observations reviews.
- Identified appropriateness of the level of care as well as issues and/or delays with treatments and services.
- Coordinated inpatient reviews of Medical-Surgical, Intensive Care and Behavioral Health with InterQual(TM) guidelines.
- Trained new Utilization Review staff on InterQual(TM) standards.
- Developed a template requiring all providers, social workers, UR and charge nurses on the assigned unit to sign.
- Generated utilization management reports and determined performance measures not being met.
- Collaborated daily with providers, nursing staff, and Physician Utilization Management Advisors.
Utilization Review Specialist I Resume
Objective : Passionate, dedicated and insightful professional seeking a challenging and rewarding position in the Social Work field as a Counselor or Therapist working with culturally.
Skills : Case Management, Utilization Review experience.
- Communicated information received to appropriate staff in a timely and efficient manner.
- Worked with the clinical/medical team to ensure, that the care manager's questions and concerns are documented in the clinical record.
- Experience to assist admissions department with placement criteria.
- Negotiated and built a rapport with payers regarding patient treatment needs.
- Managed denials and conducted doctor reviews to maintain the highest level of care.
- Performed all duties in a timely manner which may require availability on-site or via cell phone.
- Identified and reported variations in the quality and appropriateness of care using ASAM and insurance medical necessity criteria.
Utilization Review Specialist III Resume
Summary : Under general supervision, reviews client health records to ensure proper utilization of treatment resources.
Skills : Interpersonal Skills, Answering Phones.
- Managed incoming calls or incoming post services claims work.
- Determined the contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization.
- Referred cases requiring clinical review to a Nurse reviewer.
- Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
- Responded to telephone and written inquiries from clients, providers and in-house departments.
- Authorized the initial set of sessions to the provider.
- Checked benefits for facility-based treatment Develops and maintains positive customer relations and coordinates with various functions.
Utilization Review Specialist II Resume
Headline : To obtain a position as a team-player in a people-oriented organization where can maximize customer-service experience in a challenging environment to achieve the corporate goals.
Skills : Data Entry, Medical Terminology, Customer Service.
- Reviewed Specialist Screened all medical documentation and make decisions.
- Provided information to determine the most efficient and appropriate method of transport or most appropriate medical provider.
- Audited whether provider billed for previously canceled trips and/or was paid for trips that did not occur.
- Reviewed ineligible rider reports and medical necessity forms.
- Assisted with standing order recertification.
- Assisted with booking enrollee's out of state trip request by communicating with physicians and caseworkers.
- Handed enrollee's gas, hotel and flight Reimbursements.
- Trained new employees on how to understand and read the medical necessity form.
Associate Of Science
Utilization Review Specialist/Executive Resume
Headline : Customer Service Professional with experience in the healthcare industry and a specialty in credentialing information for a variety of medical professionals.
Skills : Pharmacy, Organizing.
- Authorized cases according to standard approval process documents.
- Documented clinical/non-clinical information to progress the utilization or case management process.
- Sent letters to members and providers as required. Kept spreadsheet of all cases coming in and what RN handled in the case.
- Maintained all regulatory timelines to support compliance with state and federal regulations.
- Obtained authorizations from insurance companies for acute inpatient mental health hospitalizations.
- Concurrent reviewed for continued authorizations and chart audits.
- Reviewed on pts.status to insurance companies to get authorization for continued status on pts.condition.
Utilization Review Specialist III Resume
Summary : Diversified experience in the Health Care Arena. Experienced in Psychiatric and Medical-Surgical Case Management.
Skills : Utilization Review, Discharge Planning.
- Interacted daily with team members, intake assessments assisted clients with financial resources.
- Managed financial constraints, wrote appeals for reimbursement and assisted in the quality assurance process.
- Instrumented the hospital receiving Designated Status with Blue Cross.
- Resulted in time and cost savings to the Psychiatric Department.
- Co-facilitated educational series for the nursing department known as psychiatric Grand Rounds.
- Solved complex financial billing situations resulted in money returned to clients and higher level of customer satisfaction.
- Assisted risk management to prevent and reduce litigation for the entire hospital.
Lead Utilization Review Specialist Resume
Summary : Responsible for Demonstrating effective verbal and written communication skills with internal and external customers, i.e., insurance companies, case managers, home care agencies, physicians, nursing staff and ancillary personnel.
Skills : Problem Solving Skills, Technical Skills.
- Assisted RN's on the hospital unit by contacting various insurance companies.
- Obtained authorizations for a current hospital stay using InterQual Criteria for correct status placement of patients.
- Contacted insurance companies when needed for daily inhouse reviews.
- Communicated with Security Blue and some other insurances.
- Required for authorization of MA admissions. Data Entry Prior Authorization Benefit Eligibility Concurrent Review.
- Scheduled appeal calls to overturn the denial.
- Hired as Member Services Rep.Promoted to UR dept.
LPN In Nursing
Associate Utilization Review Specialist Resume
Summary : To obtain a challenging, rewarding position in a health care facility that will enable to use strong passion for helping others, customer service skills, educational background.
Skills : Medical Terminology, Medical Insurance, Excellent Interpersonal Skills.
- Responsible for consulted with insurance companies and clinical teams to evaluate appropriateness and level of care for complex or difficult cases.
- Communicated significant findings, including potential risk improvement issues to the UR Manager or VP of Quality Assurance as indicated in a timely manner.
- Maintained regular communication with the clinical team.
- Responsible for maintained UR documents, case files, and correspondence in an organized, confidential and secure manner.
- Responsible for ensuring that Client care is coordinated and managed appropriately daily.
- Ensured that care and services are delivered appropriately and for the supervision of personnel.
- Communicated with the clinical staff when issues arise with their clients.
Utilization Review Specialist/Analyst Resume
Summary : To obtain employment where can use skills as a Licensed Practical Nurse to the best of ability to benefit employer and support the nursing staff.
Skills : Management, Problem Solving Skills.
- Verified eligibility and benefits for patients. Retro reviews requested by insurance companies.
- All pre-certifications and concurrent reviews for all managed care.
- Compiled all information for the UR department and report this to the PI department with the corporate office.
- Worked closely with our billing department as well as the credentialing officer for at corporate Accomplishments.
- Established new procedures for our UR department regarding changes to the Medicaid changes.
- Stayed knowledgable of our intake procedures and admission criteria Skills Used LPN.
- Communicated with our insurance company's and also when communicating with all Doctors.
Utilization Review Specialist Resume
Summary : To utilize skills in direct clinical care, case management services and business administration to promote community and organizational development.
Skills : Electronic Medical Records System, Data Entry.
- Directed and performed concurrent and retrospective reviews for inpatient, partial and intensive outpatient levels of care.
- Consulted with physicians, therapists and health care providers regarding treatment, discharge planning, and continuing care.
- Prepared notification letters to initiate appeals processes.
- Interpreted health care plan benefits, policies and procedures for members, physicians, therapists, and hospital administrators.
- Coordinated live telephonic reviews for physicians and payor representatives.
- Coordinated with claims and billing departments to ensure proper payment of accounts from payors.
- Facilitated Service Excellence training sessions for employees during orientation and annual requirements seminars.
Master's Of Science