Nurse Reviewer Resume Samples
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Nurse Reviewer Resume Samples
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VH
V Halvorson
Vella
Halvorson
66026 Alfreda Circles
Los Angeles
CA
+1 (555) 322 8141
66026 Alfreda Circles
Los Angeles
CA
Phone
p
+1 (555) 322 8141
Experience
Experience
San Francisco, CA
Nurse Reviewer
San Francisco, CA
Wolff-Kohler
San Francisco, CA
Nurse Reviewer
- Ensures development and design of data collection forms are in accordance with study protocol and established standards
- Assist in developing best practices and guidelines for medical record review and data collection
- Facilitates quality improvement plan development and implementation as requested, both internally and with external customers
- Provides supporting reference documentation to the reviewer
- Perform other duties as assigned
- Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services
- Comply with established departmental policies, procedures and objectives
Dallas, TX
Nurse Reviewer, Utilization
Dallas, TX
Daniel, Ondricka and Ebert
Dallas, TX
Nurse Reviewer, Utilization
- Stays abreast and complies with state/federal legislation as it applies to utilization management services
- Provides leadership, oversight and guidance to team members to ensure quality product for customers
- Maintains ongoing communication with the claims examiner/adjustor as to status of determination
- Acts as a clinical resource to non-clinical staff
- Stays abreast of healthcare industry current practices and trends
- Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations
- Maintain positive working relationships with Members, and relevant informal supports, provider organizations, and state agencies
present
Detroit, MI
Nurse Reviewer / Clinical Adjudicator
Detroit, MI
Davis, Dickinson and Schroeder
present
Detroit, MI
Nurse Reviewer / Clinical Adjudicator
present
- Render medical necessity determinations for Medicare QIC Part A cases assigned
- Resolve all other technical issues within Medicare reconsideration assigned
- Review cases to determine and summarize facts of each case assigned and assesses issues involved in the case
- May support Part A party hearings providing clinical testimony to party hearings
- May perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary
- Perform other duties as assigned by management
- Knowledge of health regulations, guidelines and coverage issues; knowledge of statistical terminology and use of statistics
Education
Education
Associate’s Degree in Health
Associate’s Degree in Health
Ashford University
Associate’s Degree in Health
Skills
Skills
- Ability to analyze and evaluate medical information.- Ability to provide good customer service skills
- Ability to work independently to meet predefined production and quality standards
- Ability to work proficiently with Microsoft Word, Excel, and Power Point.-
- Working knowledge in and successful application of basic level of health care data analysis and clinical review.Work Conditions and Physical Demands
- Working knowledge in and successful application of basic level of health care data analysis and clinical review
- Excellent organizational skills and ability to successfully prioritize multiple tasks
- Ability to medically review; chart audits, and quality improvement processes
- Strong attention to detail
- Ability to provide good customer service skills
- Ability to work proficiently with Microsoft Word, Excel, and Power Point
10 Nurse Reviewer resume templates
Read our complete resume writing guides
1
Nurse Reviewer Resume Examples & Samples
- Read and interpret claims data, medical records, and any associated medical notes related to clinical records or claims processing
- Assure compliance with state and federal regulations and billing requirements
- Research federal and state statutes, regulations, and national accrediting standards to determine criteria concerning utilization of medical services
- Accurately document and represent findings from medical reviews
- Attend internal and external meetings as directed
- Exercise discretion and independent judgment
- Bachelors degree in Health or Human Services field or work related experience
- Five years experience in medical operations
- Some experience with Microsoft Word and Excel
- RN or LPN
2
Nurse Reviewer Resume Examples & Samples
- Familiarity with ICD-9 and CPT 4 coding preferred
- Customer service experience would be helpful
- Previous clinical experience in a hospital or urgent care environment would be a plus, but not required
- Familiarity with managed health care programs including HMO, PPO, and POS be a plus
- Familiarity with ICD-9 and CPT 4 coding would be a plus
3
Nurse Reviewer / Clinical Adjudicator Resume Examples & Samples
- Render medical necessity determinations for Medicare QIC Part A cases assigned
- Resolve all other technical issues within Medicare reconsideration assigned
- May support Part A party hearings providing clinical testimony to party hearings
- May perform other special projects not related to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary
- Registered Nurse Degree from an accredited college required
- Registered nurse (RN) degree with active license required and able to meet credentialing requirements
- Knowledge of health regulations, guidelines and coverage issues; knowledge of statistical terminology and use of statistics
- Must possess strong analytical skills, problem solving and decision making skills, excellent organization
- Written and verbal communication skills, excellent computer skills
- Ability to work independently and support team members (virtually)
- Ability to independently manage workflow
- Proficient in Microsoft Office software
- Ability to quickly learn multiple database systems and comfortably manage multiple screens at the same time
- Two years of related experience required
- Home Health or SNF preferred
4
Nurse Reviewer Resume Examples & Samples
- RN Licensure and minimum 5 years clinical experience; or equivalent combination of education and experience
- Demonstrated effective written and oral communication skills
- Demonstrated computer skills
- Demonstrated ability to analyze and evaluate medical information
- Demonstrated experience in medical review, chart audits, and quality improvement processes
- Must have high speed internet access from home office
- Home-based associates will be required to occasionally travel to client headquarters
5
NGS Nurse Reviewer Senior Resume Examples & Samples
- Requires an AS/BS in nursing
- Ability to comprehend medical policy and criteria to clearly articulate health information required
- Solid understanding of the Medicare Medical Review process required
- Experience in Home Health care review and/or prior authorization/precertification is required
6
Nurse Reviewer Specialty Resume Examples & Samples
- Registered Nurse with a current, valid unrestricted license in the state of Illinois
- Minimum of three (3) years recent clinical nursing experience in an ambulatory or hospital setting
- Candidates should have good computer skills and solid typing speed and accuracy
- Familiarity with managed health care programs including HMO, PPO, and POS
- Familiarity with Utilization Management Guidelines preferred
- Previous utilization and/or quality management and/or call center experience helpful
- Quality management and/or call center experience helpful
7
Nurse Reviewer Resume Examples & Samples
- Evaluates and intervenes concurrently and retrospectively for level of care, coverage issues, payor outliers, split billing, disallowed charges, patient inquires, denial and compliance issues
- Initiates actions and participates with Patient Financial Services payor teams regarding resolution of denial management issues or compliance issues. Works with authorized payors or reviewers to resolve denial management issues, reconsiderations and appeals
- Tracks, monitors and documents denial causes and resolutions with appropriate management staff
- Acts as a knowledge resource for billing staff members. Identifies educational needs regarding payor issues, functions as preceptor, and provides appropriate education
- Builds and continually updates a knowledge of Third Party Payor requirements for covered treatment protocols by diagnosis, approval requirements for procedures, and coverage norms
- Provides education by collaborating with Care Coordination at company facilities or other staff of non-company locations on concurrent and retrospective utilization review. Accurately and thoroughly completes documentation required for claims payment of services approved through concurrent review and case management
8
Nurse Reviewer Resume Examples & Samples
- Assigns case reviews by identifying the issues for review and the specialty of the physician reviewer necessary to complete the peer matched review
- Communicates with appropriate parties regarding review (enrollee, authorized representative, health plan representative, facility and state department of insurance)
- Receives requests for precertification of procedures via telephone, fax, or Web
- Participates on quality improvement teams
- Ability to communicate both verbally and in writing fluently in English
- Ability to analyze and evaluate medical information
- Ability to travel 10%
- Ability to sit and work at a computer for an extended period of time
- Associate’s degree or diploma (Nursing program) required; Bachelor's degree preferred
- 3+ years clinical experience
- 1+ year utilization review experience
9
Nurse Reviewer Resume Examples & Samples
- Working knowledge in and successful application of basic level of health care data analysis and clinical review.Work Conditions and Physical Demands
- Primarily sedentary work in a general office environment
- Ability to communicate and exchange information
- Ability to comprehend and interpret documents and data
- Requires occasional standing, walking, lifting, and moving objects (up to 10 lbs.)
- Requires manual dexterity to use computer, telephone and peripherals
- May be required to work extended hours for special business needs
- May be required to travel at least 10% of time based on business needs
- Unrestricted RN license required
10
Nurse Reviewer Resume Examples & Samples
- Reviews assigned cases or escalated cases, to determine if Life or Disability insurance should be approved
- Examines and processes Statement of Health Applications; determines whether to return, put on pending, deny, approve or request additional medical information
- Must be able to work well within a team of 15-20 during non-peak, and a team of 40-60 during peak season
- Ability to multi-task; processing applications, answering phones, and helping people on the team with questions
- Interpersonal communication skills must be strong
- Written communications must be professional
- Review and update documentation and work instructions
- Assist in training and mentoring with temporary nurse staff
- Performs other related duties as assigned or required
- High School Diploma with Licensed Practical Nurse with current state license required
- Ability to put the team first
- 2-5 years of Insurance claims experience
- Nursing Degree with current RN state license preferred
11
Nurse Reviewer Resume Examples & Samples
- Performs clinical and medical reviews, data collection and database entry. Assigns case reviews by Identifying the issues for review and the specialty of the physician reviewer necessary to complete the Peer matched review. Provides supporting reference documentation to the reviewer. Applies state laws during the Quality Assurance process. Interacts with physician reviewers. Assists in the
- Transcription of physician reviews by editing and formatting, as needed.-Assures that all work is completed within contractual deadlines and that all components of the completed review are present
- Delivers final product to the client per client specific contractual guidelines. Communicates with Appropriate parties regarding review (enrollee, authorized representative, health plan Representative, facility and state department of insurance)
- Receives requests for pre certification of Procedures via telephone, fax, or Web.- Utilizes clinical expertise to approve services or refer requests
- To a physician for review. Oversees referrals to and from physician review. Formats and edits approval And denial letters. Performs retrospective chart review per contract specifications.- Prepares letters to Summarize retrospective review activity.- Evaluates, identifies, and reports on, quality of care issues
- Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate.- Participates on quality improvement teams.- Facilitates quality improvement plan development and implementation as requested, both internally and with External customers. - Participates in the project data analysis, reporting, and feedback processes. Other Functions: - Performs other functions as assigned
- Unrestricted RN license required Minimum Education:- Associate’s degree or diploma (Nursing program) required; Bachelor's degree preferred
- Minimum Related Work Experience:- 3+ years clinical
- Experience required- 1+ year utilization review experience preferred
- Candidate must have SNF (Skilled Nurse Facility experience)
- Ability to work proficiently with Microsoft Word, Excel, and Power Point.-
- Ability to analyze and evaluate medical information.- Ability to provide good customer service skills
- Ability to apply Existing knowledge of health care marketplace including commercial and government insurance Health plan organizations and HIPAA guidelines with their associated security requirements
- Ability to work independently to meet predefined production and quality standards- Working knowledge in and Successful application of basic level of health care data analysis and clinical review
12
Nurse Reviewer Resume Examples & Samples
- AAS in Nursing
- 3-5 years of experience in an acute care facility
- 2-3 years in a health care or managed care setting
- Chart review experience
13
Nurse Reviewer Resume Examples & Samples
- Conduct pre and post payment review of inpatient admissions, outpatient services, and other procedures to assess the appropriateness and continuity of care
- Apply all aspects of the medical review function, including pre-authorization, concurrent review, screening for quality of care issues, and discharge planning. Document rationale for medical decisions made
- Identify at-risk members who would benefit from health management programs through comprehensive health assessments
- Monitor and evaluate patient’s plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions
- Promote member and provider satisfaction. Provide continuity and consistency of care by building positive relationships between member and family, physicians, provider, care coordinator, and health care plan. Represent corporation in a responsible and professional manner
- Participate in department initiatives and projects
- Unrestricted Rhode Island Nursing License
- Three to five years acute medical or clinical experience or experience in utilization reviewed
- Valid Driver’s License (On-site only)
- Certified Case Management certification, Certified Professional Utilization Review certification
- Experience working in a managed care/health maintenance organization
- Understanding of utilization review techniques including all aspects of the medical review function, including pre-authorization, concurrent review and discharge planning
- Understanding of health care delivery system access points and services
- Correct application of health care management guidelines
- Ability to navigate the healthcare delivery system
- Good business acumen and political savvy
- Presentation skills
- Good problem solving skills
- Ability to interface with employees at all levels
- Ability to effectively navigate ambiguous situations with limited direction
- Excellent organizational skills and ability to successfully prioritize multiple tasks
- Ability to handle multiple priorities/projects
14
Quality / Safety Nurse Reviewer Resume Examples & Samples
- Collects data according to the internal design/external agency specifications including, but not limited to the Critical Care Project IMPACT database, JCAHO Core Measures, BIDMC Process Improvement Initiatives as prioritized by leadership
- Assists in compilation of data into reports for analysis by various departments and committees
- Uses query for existing internal and external databases for comparative analysis. Collects data and prepares reports required by defined internal/external specifications for performance measures
- Assists in reviewing individual cases identified by payers as quality improvement opportunities
- Associate's degree in Nursing required
15
Disability Nurse Reviewer Resume Examples & Samples
- At least 3-6 years of clinical RN experience required
- 2-3 years of case management experience in disability or related field is highly desired!
- Nursing/Orthopedics is desired!
- Nursing/Medical Surgical-Oncology Nurse is desired!
- MS Office to include Word and Outlook are needed!
16
Nurse Reviewer Resume Examples & Samples
- Serve as the clinical manager for an assigned caseload of Members
- Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of Members requiring health care services, to include outpatient and home based therapy services
- Conduct on-site reviews and assessments of Member’s community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations
- Prepare and implement Member service records
- Coordinate, facilitate and monitor the delivery of services to members
- Review and document all relevant information into data system applications in accordance with program guidelines and regulations
- Conduct routine and ad-hoc evaluations and re-evaluations of Members’ services
- Contact and engage providers, state agency offices, and Members to obtain information and records needed to conduct a comprehensive clinical review of the case and final determination
- Evaluate and document the appropriateness of Members’ services and make modifications, as required
- Maintain individual records documenting all Member encounters and contacts; write clinical summaries
- Prepare and respond to requests for statistics and resource/service data
- Foster and promote continuity of care and cooperative partnerships by liaising with health care providers, acute care hospitals and other programs/organizations involved in the provision of services
- Participate in public relations efforts, attending conferences and meetings as needed
- Maintain positive working relationships with Members, and relevant informal supports, provider organizations, and state agencies
- Maintain the confidentiality of all business documents and correspondence per UMMS/CWM procedures and HIPAA regulations
- Participate in performance improvement initiatives and demonstrates the use of quality improvement in daily operations
- Comply with established departmental policies, procedures and objectives
- Comply with all health, safety and program regulations and requirements
- Perform other similar and related duties as required or as directed
- RN licensed to practice in Massachusetts
- Bachelor’s Degree in Nursing or equivalent experience
- 5 years’ work experience with at least 3 recent years providing direct service or case management to pediatric patients or young adults with special needs
- Ability to travel statewide to Member homes and service providers places of business
- Experience with Office Application and database
- 5+ years of pediatric or young adults experience
- Experience with home care
- Knowledge of applicable state regulations
- LI-MR1
17
Nurse Reviewer Resume Examples & Samples
- Review medical records to verify services were provided and charges are accurate - Identify both overcharges and undercharges
- Identify if a discrepancy exists and document the findings using standard documentation guidelines applicable to the program
- Report any problems in the audit process to Manager for resolution
- Comply with HIPAA and other regulations regarding the confidentiality of patient information
- RN with Active License
- Minimum 5 years diverse clinical experience
- Previous auditing experience; internal or external
- CPC, CCS, CMAS
18
Inpatient Nurse Reviewer Resume Examples & Samples
- Registered Nurse with current, non restricted MA license
- BSN: Preferred
- Minimum of three years of clinical nursing experience
- Minimum 3 years of UM experience, preferably in an inpatient setting or managed care environment
- Excellent interpersonal skills to form positive and collaborative relationships
- Ability manage tasks to leverage non-clinical resources on team
- Use professional and clinical judgment to identify issues and escalate accordingly to a supervisor and relevant Tufts Health Plan departments
- Ability to apply nationally recognized standards to support utilization management
- Ability to use a laptop to accurately document utilization management activities adhering to department documentation standards
- Ability to work independently; highly motivated and self--directed with strong time management skills
- Flexibility
- Proficiency with or ability to learn technology for initiating and participating in web/system based communications: webinar, instant messaging, thin client, soft phone or others
- Proficiency with or ability to learn technology based programs such as Microsoft Word and Excel; other programs as needed
19
Nurse Reviewer Resume Examples & Samples
- Assist in developing best practices and guidelines for medical record review and data collection
- Provide clinical guidance when developing proposal responses using research and/or existing experience
- Review and edit protocols using expertise related to data that will be collected from medical records
- Help inform project-specific data collection tools based on experience across multiple therapeutic areas
- Assist in training clinical abstractors on project-specific materials, across multiple projects
- Ensures development and design of data collection forms are in accordance with study protocol and established standards
- Assists with chart audits to ensure integrity and quality of clinical data and HIPAA compliance
- Requires LPN/RN/BSN or other equivalent medical experience
- Up to one year experience in conducting research
- Experience with medical record review in various settings
- Basic medical coding experience preferred
- Strong computer skills including: Adobe Acrobat, and MS Office Suite (Access, Excel, Word, and PowerPoint)
20
Nurse Reviewer, Utilization Resume Examples & Samples
- Reviews requested treatment/procedures within Mitchell utilization review policies, URAC time frames or state-mandated timeframes (whichever is more restrictive) for determination of medical necessity and appropriateness
- Uses evidence-based, nationally recognized treatment protocols and accesses physician reviewers, as indicated, when certification/approval cannot be recommended based upon medical review criteria or clinical experience
- Facilitates communication of quality determinations verbally and/or in writing with required parties in accordance with Mitchell International policies and procedures
- Provides leadership, oversight and guidance to team members to ensure quality product for customers
- Maintains ongoing communication with the claims examiner/adjustor as to status of determination
- Acts as a clinical resource to non-clinical staff
- Stays abreast and complies with state/federal legislation as it applies to utilization management services
- Understands and complies with applicable URAC workers’ compensation utilization management standards
- Stays abreast of healthcare industry current practices and trends
21
UR Nurse Reviewer Resume Examples & Samples
- Applies state laws during the Quality Assurance process
- Interacts with physician reviewers
- Assists in the transcription of physician reviews by editing and formatting, as needed
- Utilizes clinical expertise to approve services or refer requests to a physician for review
- Oversees referrals to and from physician review
- Formats and edits approval and denial letters
- Prepares letters to summarize retrospective review activity
- Communicates with health care professionals as a liaison regarding contract specifications and escalates issues as appropriate
- Facilitates quality improvement plan development and implementation as requested, both internally and with external customers
- Participates in the project data analysis, reporting, and feedback processes
- Ability to work proficiently with Microsoft Word, Excel, and Power Point
- Ability to function under pressure and with deadline oriented project demands as well as manage multiple initiatives
- Ability to apply existing knowledge of health care marketplace including commercial and government insurance health plan organizations and HIPAA guidelines with their associated security requirements
- 3+ years clinical experience required
- 1+ year utilization review experience preferred
