Medical Nurse Resume Samples

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MG
M Gislason
Maynard
Gislason
448 Jeanie Overpass
Los Angeles
CA
+1 (555) 831 5394
448 Jeanie Overpass
Los Angeles
CA
Phone
p +1 (555) 831 5394
Experience Experience
Philadelphia, PA
Nurse Manager Medical Surgical
Philadelphia, PA
Emard Inc
Philadelphia, PA
Nurse Manager Medical Surgical
  • Addresses patient safety in the Performance Improvement Plan/Patient Safety Plan
  • Follows established guidelines for compliance with Infection Prevention and TJC Patient Safety Goals and Practices
  • Actively participates in unit and/or hospital performance improvement activities
  • Provides care in an evidenced-based environment
  • Compliance with 5 Standards of Star Service; always delivering exceptional service to our patients, physicians, guests, coworkers, volunteers and vendors
  • Practices autonomously, consistent with practice standards and research based policy/procedures
  • Exercises independent judgment within the context of interdisciplinary patient care
Boston, MA
Medical Information Nurse Manager
Boston, MA
Gerhold, Christiansen and Langosh
Boston, MA
Medical Information Nurse Manager
  • Foster participative work environment where the opinions of others are heard
  • Sound, virtual presence for operations management
  • Conduct internal monitoring sessions
  • Evaluate the amount of logic incorporated in decisions made
  • Positively embrace change and communicate in a positive manner
  • Follow escalation policies
  • Ensure that all company policies and guidelines are adhered to
present
Los Angeles, CA
Medical Information Nurse Manager, RN
Los Angeles, CA
Cummerata, Yost and Fritsch
present
Los Angeles, CA
Medical Information Nurse Manager, RN
present
  • Manage campaigns for optimal performance and work with Program Managers to ensure success of programs
  • Coach and develop representatives and help them to set up development plans and objectives
  • Sound, visible floor presence for optimal operations management
  • Perform in a mature and professional manner and lead by example
  • Create and administer representative commission payouts
  • Staff assigned programs for optimal performance
  • Manage any payroll issues for representatives
Education Education
Bachelor’s Degree in Nursing Required
Bachelor’s Degree in Nursing Required
Loyola Marymount University
Bachelor’s Degree in Nursing Required
Skills Skills
  • Ability to maintain high quality work while meeting deadlines
  • Ability to read, comprehend, review and analyze information
  • Excellent writing skills used to produce work free from typographical or spelling errors
  • Working knowledge of technology including Microsoft Office, Internet and e-mail
  • Ability to travel up to 35%
  • Ability to communicate and exchange information
  • Registered nurse with license in good standing
  • Knowledge reviewing Medicare Part A and Part B pre-payment or post-payment medical record review as well as Medicaid medical record review as requested
  • Ability to complete extensive reading and research
  • Excellent verbal communication and writing skills used to produce work free from typographical or spelling errors
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8 Medical Nurse resume templates

1

Medical Review Nurse Resume Examples & Samples

  • Current RN or LPN/LVN license is required
  • Strong communication and organization skills
  • Strong PC knowledge and skills
  • Ability to present issues of concern, citing regulatory violations, alleging schemes or scams to defraud the Government
  • Ability to research regulations and cite violations
  • Ability to conduct self-directed research to uncover problems in Medicare payments made to institutional and non-institutional providers
  • Ability to communicate effectively, internally and externally
  • Ability to handle confidential material
  • Ability to attend meetings, training, and conferences, overnight travel required
2

Nurse Liaison for IPA Medical Management Resume Examples & Samples

  • Work with all the departments within Humana for assistance in problem solving with Delegated Providers
  • Monitor receipt of IPA’s required UM Delegation Reports
  • Excellent PC skills (including MS Word, Excel and PowerPoint)
  • Bachelor’s Degree in health- or business-related field
3

Medical Information Nurse Manager Resume Examples & Samples

  • An understanding of terminology used in reports and documentation and internal TMS systems
  • Accountable to meet productivity goals for assigned programs
  • Monitor daily productivity reports
  • Handle representative questions and concerns
  • Write and deliver representative evaluations
  • Promote high levels of motivation and morale
  • Manage any payroll issues for representatives
  • Create and administer representative commission payouts
  • Foster participative work environment where the opinions of others are heard
  • Attendance dependability and punctuality
  • Positively embrace change and communicate in a positive manner
  • Follow escalation policies
  • Healthcare, pharmaceutical or telemarketing management experience preferred
  • Demonstrated leadership, initiative and professional behavior
  • Strong computer and keyboard ability with advanced knowledge in Microsoft Office Suite including Word, Excel and Outlook
  • Ability to present in a polished and highly-articulate manner
  • Demonstrated organizational and time management skills with ability to manage programs effectively
  • Ability to perform in high-pressure and fast-paced environment and handle multiple tasks simultaneously
4

Rn-nurse Medical Management Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of Nevada
  • 2 years acute care clinical experience. Strongly prefer discharge planning experience
  • Willingness to work Pacific time zone hours / work schedule
5

Nurse Medical Mgmt, / II / Senior Resume Examples & Samples

  • Ensures member access to medical necessary, quality healthcare in a cost effective setting according to contract
  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process
  • Facilitates 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
6

Nurse Medical Management Resume Examples & Samples

  • Work from home position but you must live in the following states to be considered; NY, NJ, VA, TN, FL, TX, MA, CT, DE, PA, NC, or GA
  • Full time position (Monday - Friday 8 AM to 5 PM EST
  • An unrestricted NY RN license is required. (You must have one of these currently to be considered, will have to obtain the others once employed)
  • 2 years RN/LPN clinical experience working with acute physical health
  • 2 years utilization management experience
  • Experience working with electronic documentation and multiple databases
  • Current unrestricted RN license in NY, even if you do not reside there
  • Current unrestricted RN license in current state
7

Nurse Medical Mgmt Resume Examples & Samples

  • Requires AS/BS in nursing and 3 - 5 years acute care clinical experience (2 years for the Nurse Medical Management l), preferably adult care (i.e. Medical surgical or ICU); or any combination of education and experience, which would provide an equivalent background
  • Prior managed care experience with a Utilization Management focus or hospital based case management/ discharge planning is required
  • Knowledge of the Continued stay review process is required
  • Must have excellent communication skills (written and verbal) and interpersonal skills
  • Experience with Medi-cal is preferred
  • Must be able to work 8 - 10 hour shift on Saturday AND Sunday - flexible work schedule
8

Nurse Medical Mgmt, Ltss Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional in the state of Iowa and 3-5 years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background
  • Requires previous experience serving members in disabilities, elderly members and/or Long Term Care populations
  • Requires previous experience with Medicaid waiver
  • Previous Utilization Management experience preferred
  • Prior managed care experience strongly preferred
9

Chief Nurse Executive South Sacramento Medical Center Resume Examples & Samples

  • Works collaboratively with labor partners to achieve organization goals and objectives
  • Maintains strong collaborative relationship with medical director and medical staff leadership and coordinates with medical group partners to provide for the seamless transition of patients across the continuum of care
  • Communicates effectively as hospital's advocate to members of the community, continually seeking ways to improve and promote the public relations objective of the hospital and marketing services
  • Maintains role-specific KP Health Connect competencies
  • Minimum seven (7) years of progressive experience in clinical, management and leadership roles within hospital operations
10

Medical Information Nurse Manager, RN Resume Examples & Samples

  • Sound, visible floor presence for optimal operations management
  • Manage campaigns for optimal performance and work with Program Managers to ensure success of programs
  • Ensure that high call quality is maintained and monitored, providing coaching as needed
  • Conduct internal monitoring sessions
  • Ensure that daily/weekly statistical project reports are updated, accurate and delivered on time
  • Conduct training for programs as needed
  • Staff assigned programs for optimal performance
  • Handle any disciplinary issues
  • Coach and develop representatives and help them to set up development plans and objectives
  • Recognize problems and propose solutions and follow through with implementation
  • Perform in a mature and professional manner and lead by example
  • Set and meet realistic deadlines
  • Evaluate the amount of logic incorporated in decisions made
  • Act as liaison to IT help desk and facilities department as needed
  • Ensure that all company policies and guidelines are adhered to
  • Exceptional client contact experience required
  • Ability to manage programs effectively
  • Excellent verbal and written communication and listening skills
  • Ability to effectively work independently and coordinate team efforts
  • Proactive and highly motivated
  • Well-developed problem analysis and decision-making skills
11

Nurse Clinician, Medical Case Manager Resume Examples & Samples

  • Client monitoring to assess the efficacy of the plan
  • Periodic re-evaluation and adaptation of the plan as necessary over the life of the client
  • Responsible for patient specific health education, monitoring, assessment and deployment of techniques to assure the engagement and retention in care of the identified patients
12

Nurse Medical Management Resume Examples & Samples

  • Requires AS/BS in nursing and 3 - 5 years acute care clinical experience, preferably adult care (i.e. Medical surgical or ICU); or any combination of education and experience, which would provide an equivalent background
  • Current unrestricted California RN license required
  • Must have experience summarizing findings to higher level medical staff
  • Experience analyzing and auditing medical records
  • Excellent computer skills with knowledge of Microsoft applications required
13

Resgistered Nurse Medical Intermediate Resume Examples & Samples

  • Assists physician with insertion of central venous catheters or other venous access devices, as needed
  • Does assessment and intervention for patients with wound ulcers
  • Assumes the responsibility of charging the unit, as needed
  • Responsible for maintaining customer friendly atmosphere
  • Scanning supplies from P.O.U. area
  • Minimum of one (1) year current/recent Medical Tele experience
14

Nurse Manager, Medical Dept Resume Examples & Samples

  • 3 years of Occupational Health or Public Health field
  • 5 Years as supervisor/manager in related field
  • Excellent personal communication and diplomacy skills
  • Solid computer, social media and presentation skills
  • Seasoned professional with the ability to manage difficult situations
  • RN license in State of New York
  • CPR BLS certification
  • 2-5 years nursing experience in Emergency medicine or Critical Care
  • Bachelors degree, RN
15

Nurse Manager, Medical Dept Resume Examples & Samples

  • 5-7 years in Occupational Health field
  • 5-7 years as supervisor/manager in related field
  • Seasoned professional with the ability to manage difficult situations and leverage limited resources
  • “Can do” attitude
  • RN License in state of California
  • 5-7 years nursing experience in Emergency medicine or Critical Care
  • Bachelor’s Degree, RN
16

Nurse Medical Management Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in Georgia and 2 years acute care clinical experience. Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
  • Must have at least one (1) year of utilization management experience in prior-authorization, acute, and/or post-acute
  • Travel between different care settings required to specific assigned geographic area
  • Must have knowledge and background in Medicare Advantage
  • Employer Retiree Group account experience preferred
  • May be a Nurse Medical Management I, II, or Sr depending upon level of relevant experience.**
17

Nurse Medical Management Lead Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in Georgia and 5 or more years acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background
  • Certification in the American Association of Managed Care Nurses preferred
  • May be required to work some corporate paid holidays and/or weekends based on business needs
  • Prior or current Medicare experience strongly preferred
  • Previous Employer Group Retiree account experience a plus!
18

Consultant Nurse, Medical Information Resume Examples & Samples

  • BSN, Associates Degree in Nursing or equivalent and relevant formal academic / vocational qualification
  • Associates degree and Nursing diploma candidates require 2 years of Nursing experience
  • North Carolina RN license required or Nurse Licensure Compact (NLC) equivalency
  • In some cases a second language may be required
  • Previous experience that provides the knowledge, skills and abilities to perform the job (comparable to 0-2 years) or equivalent combination of education, training and experience
  • Excellent English language skills (comprehension, speaking, reading and writing)
  • Demonstrated time management skills
  • Ability to work in a team environment and/or independently as needed
  • Demonstrate confidence and initiative
19

Medical Review Nurse Resume Examples & Samples

  • Perform a clinical review of medical records and/or other documentation to determine that services billed to and paid by the Medicaid agency are supported. This includes review for correct coding and medical necessity
  • Complete medical review form, accurately documenting findings, and provide policy/regulatory support for determination
  • Conduct research on relevant State specific billing/reimbursement regulations
  • Integrate knowledge of Medicaid/Medicare claims and reimbursement requirements to make accurate claim determination
  • Use knowledge of fraud, waste and abuse definitions to identify and participate in fraud referral when indicated
  • Provide support to internal staff, subcontractors and providers with respect to Medicaid related issues
  • Conduct claim research using the appropriate systems
  • Attend on-site visits to retrieve medical records and conduct provider entrance and exit conference
  • Participate in and contribute to the quality management system
  • Meet project timelines and deliverables
  • Work with Project Team to prepare and write audit documents
  • Serve as Project Lead for selected audits as required
  • Warehousing and memorializing documents
  • Any other duties as assigned
  • Knowledge and adherence to HIPAA Privacy and Security Rules and CMS security requirements
  • Familiarity with coding principles to include ICD-9, CPT, HCPCS, DRG and RBRVS. CPC is preferred
  • Familiarity and thorough understanding of billing forms, RA’s, EOB’s and provider billing statements
  • Familiarity with Medicaid rules and regulations is required
  • Ability to maintain high quality work while meeting deadlines
  • Excellent writing skills used to produce work free from typographical or spelling errors
  • Working knowledge of technology including Microsoft Office, Internet and e-mail
  • Ability to travel up to 35%
  • Registered Nurse with current license is required
  • CPC Preferred
  • Not currently sanctioned or excluded from any program operated by Federal or State Agencies including Medicare and Medicaid
  • 3+ years’ experience with clinical medical record auditing
  • Minimum three years’ experience as a professional health care provider
  • Clinical work experience is preferred
20

Medical Review Nurse Resume Examples & Samples

  • Ability to read, comprehend, review and analyze information
  • Ability to work well in a high stressed, fast paced, constantly evolving environment; Requires performing a variety of duties, often changing from one task to another
  • Required to perform tasks with frequent interruptions or distractions in a moderately noisy office environment
  • Frequently required to remember information and details to successfully perform the job
  • Must be able to organize workflow, prioritize tasks, meet deadlines and be flexible when working in a team
  • Is frequently required to work from the assigned office location and may be occasionally allowed to attend meetings virtually
  • Frequently required to analyze information and data; arrive at a conclusion; to study the factors of a situation or problem in order to determine the solution or outcome
  • Frequently perform mathematical calculations
21

Medical Review Nurse Resume Examples & Samples

  • Perform a clinical review of medical records and/or other documentation to determine that services billed to and paid by Medicare and/or the Medicaid agencies are supported. This includes review for correct coding and medical necessity
  • Ability to access and interpret clinical information and/or other documentation as it is related to designated review criteria in order to ascertain review determinations
  • Complete medical review in the designated systems and/or appropriate forms, accurately documenting findings, and provide policy/regulatory support for determination
  • Conduct research on relevant Medicare and/or State specific Medicaid billing/reimbursement regulations as requested to make accurate claim determinations
  • Provide support to internal staff, subcontractors and providers with respect to Medicare and/or Medicaid related issues
  • Attend on-site visits to retrieve medical records, conduct provider and/or beneficiary interviews as requested, and conduct provider entrance and exit conference
  • Participate in Administrative Law Judge (ALJ) hearings when requested
  • Provide testimony on behalf of completed reviews at civil/criminal trails, as necessary
  • Adheres to internal quality control processes to assure the reliability of project reviews and meet and/or exceed The Company’s productivity and quality review standards
  • Participate in and contributes to internal process improvements
  • Participates in and contributes to departmental meetings and on-going training programs
  • Work with Project Team to prepare and write audit documents as requested
  • Familiarity with coding principles to include ICD-9, ICD-10, CPT, HCPCS, DRG and RBRVS. CPC is preferred
  • Familiarity and thorough understanding of billing forms, RA’s, EOB’s and provider billing statements is preferred
  • Familiarity with Medicare and/or Medicaid rules and regulations is required
  • Excellent verbal communication and writing skills used to produce work free from typographical or spelling errors
  • Analytical, problem-solving and decision-making skills
  • Ability to complete extensive reading and research
  • Ability to work extended hours as needed
  • Knowledge reviewing Medicare Part A and Part B pre-payment or post-payment medical record review as well as Medicaid medical record review as requested
  • Registered nurse with license in good standing
  • 3+ years healthcare experience in a provider organization
  • >1 year experience performing medical records review or utilization review preferred
  • Background in same or similar arena as Medical Review Nurse work
22

Nurse Medical Mgmt Resume Examples & Samples

  • Requires AS/BS in nursing and 3-5 years acute care clinical experience, preferably adult care (i.e. Medical surgical or ICU) or any combination of education and experience, which would provide an equivalent background
  • Requires a current unrestricted California RN license
  • Knowledge of the Continued Stay Review process is preferred
  • Requires excellent computer skills with knowledge of Microsoft applications (Word, Excel, Outlook)
  • EPIC proficiency is a plus
  • Must be comfortable with ability to troubleshoot computer IT problems if based from home (Remote IT assist via phone)
23

Nurse Manager, Acute Medical / Surgical Unit Resume Examples & Samples

  • Nursing BSN degree
  • Must be a Registered Nurse with a minimum of 3-5 years hospital management experience
  • Licensure in professional specialty as required by the State of Indiana
  • Demonstrates good skills in all forms of communication
  • Certification: BLS must be maintained throughout employment with Terre Haute Regional Hospital
  • Masters degree in profession, healthcare administration or business administration
  • Five years healthcare experience
  • Progressive supervisory experience in specialized field
24

is Virtual Nurse Program Coordinator Adult Inpatient Unit-medical Resume Examples & Samples

  • Collaborates with project team to design and test novel processes, leveraging technology to provide more efficient and effective models of care
  • Supports implementation of the project and evaluation of the impact of the new framework on quality measures
  • Supervises/provides oversight to the Virtual Nurses provision of patient care coordination, quality surveillance, admission/discharge coordination, physician rounding and employee mentoring and education, specifically as it pertains to the aims of the project
  • Advises/assists in training of new Virtual Nurses as the project progresses
  • Maintains knowledge of the role of the nurse and evolving technologies to improve communication for the care delivery model
  • Actively pursues the design and development of the Virtual Nursing Care Model that centers on the use of information and collaboration technologies that create “virtual” human interactions. Those interactions support efficient, effective patient/family centered care, establish a virtual support system for nurses, and potentially improve care outcomes
  • Seeks solutions to the gaps/barriers as identified by project team
  • Designs and tests the Clinical Nurse Leader (CNL) role in a virtual environment
  • Responsible for guiding the integrity of the aims and hypothesis identified within the confines of the grant
  • Leads and organizes meetings to support team function
  • MSN within five years
  • Valid Basic Life Support (BLS) certification required
  • A minimum of five years of healthcare experience required and/or demonstrated knowledge of healthcare operations
  • Preference for demonstrated experience in developing and implementing customer service initiatives
  • Excellent oral and written communication skills; clearly and succinctly articulates thoughts and ideas, builds consensus and is a persuasive presenter
  • Demonstrates a positive approach to problem-solving and issue resolution
  • Ability to work independently and with a wide variety of people
  • Ability and desire to work in a team environment, handle multiple demands and to respond rapidly to changing priorities
  • Computer and software skills including word processing and database management are necessary
25

Medical Qualifications Nurse Resume Examples & Samples

  • Review medical qualification of new hires, job transfers, certification examinations
  • Advise Law Department of medical facts in EEOC complaints on failure to hire
  • Request medical information to clarify medical conditions identified on exams
  • Coordinate enhanced strength testing implementation and reporting
  • Coordinate with HR, LR, and Field Supervisors in scheduling and processing medical exams
  • Miscellaneous activities and responsibilities as assigned by manager
  • Associate's degree from an accredited institution required in Nursing or health-related field
  • 7 or more years of work experience in the medical field required
  • License(s): Registered Nurse (RN)
  • Bachelors degree from an accredited institution required in Nursing or health-related field
  • 5 or more years of experience in the medical field required
  • Knowledge of Federal Railroad Administration (FRA) Medical Standards
  • Knowledge of FRA Conductor and Engineer certification requirements
  • Knowledge of FRA drug testing requirements
  • Knowledge of railroad work environment
  • Knowledge of labor agreements
  • Knowledge of Commercial Driver's License (CDL) medical requirements
  • Customer service skills , Oral and written communication skills
  • Microsoft Office skills (Word, Excel, PowerPoint)
  • Ability to interact effectively in a fast-paced environment
  • Ability to maintain a high degree of professionalism and confidentiality
26

Summer Graduate Nurse Program Medical\surgical Units Pipeline Resume Examples & Samples

  • Performs as ongoing assessment, formulates nursing diagnosis and goals, plans appropriate interventions, and evaluates the outcome of the interventions
  • Provides appropriate teaching and information to patients and families including information on Pain Management, Nutrition, Skin Integrity, Fall prevention, Diabetes, Disease Process, Smoking Cessation, and Discharge instructions
  • Uses interventions substantiated by research as appropriate in the patient population, Participates in research activities, identifies opportunities for research, and collaborates with the Outcomes managers and department
  • Participates in quality of care activities, evaluates the quality and the effectiveness of nursing practice. Assists in collecting quality data, analyzes the data, and formulates action plans to improve quality care
27

Medical Clearance Nurse Gi-boca Raton Outpatient Surgery & Laser Center Resume Examples & Samples

  • Check updated schedule each morning and prepare charts and calculate patient arrival times
  • Access online assessment forms, emailed or faxed orders and H&Ps, retrieve phone messages
  • Assess each patient chart for completeness and communicate with physician offices to complete
  • Call each patient with preoperative instructions and arrival time
  • Obtain patient medical/ surgical history and document appropriately
  • Arranges transportation for patients as needed
  • Communicates relevant information to Medical Director, physicians, managers and appropriate staff
  • Be able to multi-task and manage work within the designated assigned time frame
  • Current Florida RN License
  • At least one year of medical/surgical experience required
  • Exceptional assessment skills
  • Good organizational skills including a calm, reassuring telephonic voice
  • Must be available flexible hours. Shift start and length flexes with endoscopy schedule
28

RN Nurse Medical Mgmt Lead Resume Examples & Samples

  • Must have knowledge of the medical management process and ability to interpret and apply member contracts, member benefits, and managed care products
  • Managed care/long term care experience preferred
  • Computer skills: MS Office (Word, Outlook, Excel)
  • Requires strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills
29

Nurse Medical Mgmt Family, or, California Resume Examples & Samples

  • Prior Authorization Utilization Management review preferred
  • The following are level distinctions not required for posting
  • This level responds to more complex medical issues, serves as resource to lower-leveled nurses, and may participate in or lead intradepartmental teams, projects and initiatives
30

Medical Claim Review Nurse Resume Examples & Samples

  • Evaluates medical records and/or medical notes providing clinical expertise on coding accuracy
  • Reviews for provider reconsideration requests related to claim edits and validation outcomes
  • Utilizes established criteria for review of complex medical claims and refers to Chief Medical Officer or Medical Director for determinations when criteria are not met
  • Acting as a clinical resource, provides clinical review of claims to determine coding and billing accuracy and medical appropriateness of various types of provider claims
  • Reviews claims for correct billing and coding using Medicare Provider Manual guidelines. Documents clinical review summaries, bill audit findings and audit details in the data base
  • Identifies and reports quality of care issues to the Quality Management Department
  • Reports suspected member or provider fraud per Molina Healthcare Policy
  • Participates in the development and implementation of proactive approaches to improve and standardize overall retrospective claims review.To provide clinical expertise in the application of medical and reimbursement policies within the claim adjudication process through claim review, medical record review and research. To provide expert knowledge in CMS, NCCI, AMA and other nationally published guidelines for correct coding and billing accuracy. Demonstrated ability to communicate, problem solve, and work effectively with people
  • Excellent organizational skill with the ability to manage multiple priorities
  • Work independently and handle multiple projects simultaneously
  • Knowledge of applicable state and federal regulations
  • In-depth knowledge of ICD-9, CPT and HCPCS coding and guidelines
  • Knowledge of SSI, COB, and TPL programs and integration
  • Knowledge of Interqual, CMS billing and coding guidelines
  • Understanding of claim edit policies
  • Ability to take initiative and see tasks to completion
  • Computer skills and experience with Microsoft Office Products
  • Ability to abide by Molina's policies
  • Ability to maintain attendance to support required quality and quantity of work
  • Maintain confidentiality and comply with Health Insurance Portability and Accountability Act (HIPAA)
  • Skilled at establishing and maintaining positive and effective work relationships with coworkers, clients, members, providers and customers
31

Medical Clearance Nurse Resume Examples & Samples

  • Check updated schedule each morning and assemble charts
  • Gather completed on line health histories
  • Call each patient, review or complete their history and medication lists and document clearly
  • Assess patient’s baseline status and escalate relevant information to anesthesia as necessary
  • Provide clear and concise preoperative instructions to patient and/or caregiver
  • Gather and collate all physician H&P’s, orders, medical clearances etc
  • Ensure charts are prepared, complete and in order for next surgical day
  • Sets priorities to facilitate the flow of patient calls efficiently
  • At least 1 year prior preop or medical clearance experience
  • Ability to work quickly and effectively while maintaining a calm atmosphere
  • Must be available flexible hours
32

Medical Claim Review Nurse Resume Examples & Samples

  • Evaluates medical claims and/or medical records by applying clinical expertise to assess appropriateness of service provided, length of stay and level of care
  • Assists with Complex Claim review; requires decision making pertinent to clinical experience
  • 3-5 years Clinical Nursing experience
33

Nurse Medical Management Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in Texas or Virginia and 2 years ( 3 years for level II) acute care clinical experience or case management, utilization management or managed care experience, which would provide an equivalent background
  • 1-2 years utilization review/utilization management experience working with prior, concurrent and retrospective authorizations and appeals
  • Working knowledge of Milliman or InterQual criteria preferred
  • Must be able to prioritize, plan, and handle multiple tasks/demands simultaneously
  • Experience working with Federal and State assistance programs (Medicare/Medicaid) preferred
  • Experience in/with Managed Care Organization (Health Plan/HMO/MSO/TPA/IPA/etc) required
  • Participation in the American Association of Managed Care Nurses is a plus
  • Good computer literacy (MS Office) and typing skills
  • Strong oral and written communication skills; ability to interact within all levels of the organization as well as with external contacts
  • Facets, Interqual, and/or Milliman medical management systems preferred
34

Medical Claim Review Nurse RN Resume Examples & Samples

  • Identifies and refers all cases not meeting medical necessity criteria and guidelines to the Lead for evaluation
  • Identifies and refers members with special needs to the appropriate Molina Healthcare program per policy/protocol
  • Documents clinical review summaries, bill audit findings and audit details in the database
  • Provides supporting documentation for denial and modification of payment decisions
  • 1-3 years clinical nursing experience, including 1 year Utilization Review and/or Medical Claims Review experience
35

Nurse Medical Management, / II Resume Examples & Samples

  • Medical/Surgical experience
  • ER experience
  • Ability to handle mutli systems
36

Medical Review Nurse Resume Examples & Samples

  • Promotes hospice philosophy
  • Performs routine and non-routine compliance reviews
  • Completes routine compliance chart reviews as requested every month
  • Completes non-routine compliance reviews as requested
  • Records findings
  • Communicates findings with the SVP of Clinical Services, Regional Clinical Director and Director of Clinical Services
  • Provides education in the form of verbal and written regarding findings of the compliance reviews
37

Medical Claims Review Nurse Rn-telecommute Resume Examples & Samples

  • Perform clinical coverage review services, which require interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
  • Acts as a resource for others with less experience
  • A current unrestricted RN license in the state of residency
  • Exemplary clinical documentation skills; critical thinking skills
  • Must have a designated work space and access to install secure high speed Internet via cable/DSL in home. (WIFI, satellite, microwave, etc...do not meet this requirement)
  • Background involving utilization review for an insurance company or experience in case management
  • Demonstrated written proficiency for Spanish
38

Medical Policy Analyst Nurse Resume Examples & Samples

  • Coordinate special clinical studies related to focus areas identified for review. Analyze data, identify opportunities for improvement, and report results
  • Develop and maintain Medical and Pay Policies (HealthPlan coverage policies). Ensure that the policies reflect the most current medical evidence of effectiveness and patient safety, meet regulatory requirements, and reflect NCQA and AHRQ standards
  • Submit TAC recommendations to the Benefits and Reimbursement Committee
  • Support and work with projects internally and externally related to Medical Management as determined by the Senior Medical Director of Medical Policy
  • Support the Technology Assessment Committee (TAC) by researching new medical technologies and presenting information to the Committee
  • Support the member complaint and grievance process from the Medical Management perspective
  • 3 years of experience in managed care with an understanding of NCQA standards preferred
  • Ability to prioritize multiple projects and meet expected deadlines required
  • Excellent verbal and written communication and interpersonal skills required
  • Ability to interpret data/information, recognize trends and identify appropriate goals required
39

Medical File Review Nurse Resume Examples & Samples

  • Collaborating on liability claims and claims cases that have litigation activity
  • Provide subject matter expertise and partnership as a resource to claims
  • Confirm acceptable standards of medical care by utilizing clinical expertise and professional judgment as supported by established criteria documented in accepted peer reviewed research
  • Provide recommendations for action to the claims adjuster or attorney
  • Document claims file by accurately capturing and updating claims data/information in compliance with best practices
  • Ensure customer service by proactively communicating information, responding to inquiries, and following customer protocols
  • Maintain professional and technical knowledge by participating in educations opportunities, staying current with industry trends, establishing personal networks, and participating in professional societies
  • Juris Doctor and 1 or more years of experience in the Managed Care area
  • Certified Case Management (CCM), Certified Nurse Life Care Planning (CNLCP)
  • Knowledge of Medicare set asides
  • Knowledge of research criteria for establishing standards of care
  • Ability to collaborate across work groups
  • Ability to effectively present information in written reports to customers
  • Advanced Microsoft Excel and Word skills
  • Strong verbal and written communication skills, as well as presentation skills
  • Experience in a work environment that required professional and personal effectiveness in establishing relationships with claims partners, peers, and management
40

Nurse Director of Medical & Oncology Resume Examples & Samples

  • Manages the fiscal and clinical operations of assigned area(s) of responsibility and recommends sufficient number of qualified competent persons to provide care
  • Participates in outside source selection for needed services
  • Develops department budget in collaboration with CNO
  • Conducts ongoing assessment and improvement of the department’s performance. Promotes the Quality Management program of the facility maintaining appropriate quality control programs (where applicable). Oversees and drives performance in quality metrics, patient safety and clinical excellence initiatives
  • Participates in strategic planning: Develops, markets, implements, and evaluates new services and programs recommending space and resources needed
41

Medical Policy Analyst Nurse Resume Examples & Samples

  • Associate's and/or Bachelor's Degree in a Nursing and/or a Health related field; Diploma from an accredited Nursing school
  • Working knowledge of Lotus Notes
  • Solid analytical skills
  • Basic knowledge of Healthcare contracts and Benefit Eligibility requirements
  • Experience working with Medical policy, Claims Review and/or Appeals
  • Knowledge in the use of Intranet and Internet Applications
42

Nurse Medical Management Resume Examples & Samples

  • Requires an AS/BS in nursing; 2 years of acute care clinical experience (3 years and 5 respectively for higher level); or any combination of education and experience, which would provide an equivalent background
  • Requires current unrestricted RN license in state of residence
  • Must have current or previous utilization management experience
  • Experience with D-SNP and/or Medicare/Medicaid benefits a plus
  • SNF (Skilled Nursing Facility) reviews and/or 2+ acute hospital clinical experience preferred
  • Knowledge of established clinical guidelines preferred (Interqual or Milliman)
  • Must have good computer and typing skills
  • *Position may be a Nurse Medical Management I, II, or Srdepending upon level of incumbent's education and relevant skills/experience.***
43

Nurse Case Mgr-medical Oncology Resume Examples & Samples

  • Organize and prioritize daily work by assessing new, current, and discharging patient needs in area(s) of responsibility. Complete documentation as required
  • Performs utilization review activities to provide patient appropriate, timely, and cost effective care. Coordinates care with patient, care providers, hospital financial services, and third-party payers
  • Screens and coordinates the discharge planning process from patient admission to departure. Assess patient needs, develops a discharge plan, and coordinates with internal and external services for care during and after the hospital stay
44

Student Nurse Apprentice, Medical Oncology Resume Examples & Samples

  • Certificate from the State Board of Nursing to practice as a Nurse Apprentice
  • Current nursing student in good academic standing
  • Completed Basic Fundamentals of Nursing
45

Rn-nurse Medical Management Resume Examples & Samples

  • Requires current active unrestricted RN license to practice as a health professional within the scope of practice in the state of West Virginia
  • 2 or more years acute care clinical experience
  • Proficiency in MS Office / computer skills very strongly preferred
46

Nurse Medical Mgmt, or, CA Resume Examples & Samples

  • Prior managed care experience with a Utilization Management focus, or hospital-based case management/discharge planning is preferred
  • Requires strong organization skills, time management skills and be able to work in a virtual environment
  • Managed Care and Medi-cal experience is preferred
47

Rn-nurse Medical Management Resume Examples & Samples

  • Knowledge of the Continued stay review process
  • Experience with Electronic medical records is a plus
  • Must be able to work independently and be able to multi-task
  • Health plan background is preferred
48

Clinical Nurse Bsn-wvh Medical Services Resume Examples & Samples

  • ACLS from the American Heart Association (within 6 months of hire)
  • PALS from the American Heart Association or ENPC (within 6 months of hire)
  • TNCC if schedule is night shift (within 6 months of hire)
  • Telemetry Course (within 1 month of hire)
  • Pro-ACT (within 6 (six) months of hire)
  • POC testing – Glucose and Hemoccult
  • Equipment in-services as needed
  • Annual Nursing Competency Day
  • Annual Code Blue Drill
  • Ability to serve as team leader
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Nurse Medical Mgmt Family, or, California Resume Examples & Samples

  • Conducts precertification, 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
  • Collaborates with providers to assess members needs for early identification of and proactive planning for discharge planning
  • Prior work experience with CCS, IPA & Capitated providers; claims payment systems preferred
50

Nurse Manager Medical Surgical Resume Examples & Samples

  • Exercises independent judgment within the context of interdisciplinary patient care
  • Delegates tasks appropriate to meet the needs of the individual patient and to the skills of the employee supervised
  • Participates in and encourage staff participation in performance improvement as an educational experience and a tool for continual improvement of quality of care and nursing sensitive indicators
  • Delivers patient care and/or department service in a safe, competent, and efficient manner as determined by outcomes, quality monitors, and other internal and external processes
  • Maintains and enhances skills through consultation with interdisciplinary team members, participation in planning activities, and attendance at in-service and continuing education programs. Completes mandatory education, including, but not limited to, infection control, patient safety, quality improvement, MSDS and OSHA standards (PPE, First Aid and Bloodborne Pathogens, Hazard Communications, Emergency Procedures and Job Safety)
  • Follows established guidelines for compliance with Infection Prevention and TJC Patient Safety Goals and Practices
  • Education:BSN required; MSN or Masters Degree in related field preferred
  • Licensure/certification/registration: Texas State RN license or compact license is accepted, National Specialty Certification or plan to achieve within 1 year of hire. BLS/ACLS as required by individual departments (see Unit Spec Competency)
  • Experience:Minimum 2 years in a nursing management position
  • Special Skills & Qualifications:Ability to listen, interact and communicate verbally and in writing
51

Nurse Medical Mgmt, / II / Senior Resume Examples & Samples

  • Ability to talk and type at the same time
  • Demonstrate critical thinking skills when interacting with members
  • Experience with (Microsoft Office) and/or ability to learn new computer programs/systems/software quickly
  • Ability to manage, review and respond to emails/instant messages in a timely fashion