Review Nurse Resume Samples

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F Parker

Fritz

Parker

71514 Mayert Plains

Phoenix

+1 (555) 520 8461

71514 Mayert Plains

Phoenix

Phone

p +1 (555) 520 8461

Experience Experience

Philadelphia, PA

Clinical Review Nurse

Philadelphia, PA

Batz, Carter and Marvin

Philadelphia, PA

Clinical Review Nurse

Assist in clearing claims for billing as indicated
Collaborate with other departments to ensure all information to support services rendered is identified
Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses
Complete timely and accurate appeals and/or clinical reviews using established processes
Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services
Identify and assign a root cause to each case to ensure denial reasons are tracked
Maintain collaborative relationships with utilization management and appeal departments at payor organizations

Philadelphia, PA

Retrospective Review Nurse

Philadelphia, PA

Jacobi, McGlynn and Dickinson

Philadelphia, PA

Retrospective Review Nurse

Follows up on obtaining missing medical records prior to deadlines
Obtains approved authorization numbers via on-line access or telephone, depending upon the states’ agencies
Certification in Managed Care Nursing
Successfully receive interim approval for government security clearance (eQIP - Electronic Questionnaire for Investigation Processing)
Checks authorization requests for completeness and accuracy prior to submitting to Medicaid agencies
Acts as resource for decision making party to ensure that a clinically sound decision is administered
Current RN license in state where employed

present

Houston, TX

Medically Managed Bill Review Nurse

Houston, TX

Spencer Inc

present

Houston, TX

Medically Managed Bill Review Nurse

present

Researches and assists in development of new company programs or policies.Assist in evaluation and refinement of existing policies
Establishes and maintains effective working relationships with patients and their families, providers and payers
Perform within professional practice guidelines set forth by state Board of Nursing and Division of Worker’s Compensation
Manage cases to conclusion, and ensure that the goals identified in the condition management plan are met (Associate Level)
Make recommendations to achieve maximum efficiency
Performs certification of services/procedures (concurrent and retrospectively) – Associate Level
Supports the Utilization Review process, including certification of services/procedures based upon national benchmarks (Assistant Level)

Education Education

Bachelor’s Degree in Nursing Preferred

Strayer University

Bachelor’s Degree in Nursing Preferred

Skills Skills

Strong attention to detail
Knowledge of UAS-NY assessment
Solid documentation skills
Portable 401(k) plans
Access to a comprehensive employee benefits package including health, prescription, vision, dental, and life and short-term disability insurance
Previous Quality Improvement experience
Microsoft Office/Suite proficient
Great interpersonal skills
Excellent communication skills (written and verbal)
Highly organized

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Medicare Review Nurse Resume Examples & Samples

Current RN license required
Strong investigative skills
Experience in reviewing claims for technical requirements, performing medical review, and/or developing fraud cases
Ability to make claim payment decisions based on clinical knowledge
Ability to compose correspondence, reports and referral summary letters
Ability to report work activity on a timely basis
Ability to work independently and as a member of a team to deliver high quality work

Review Nurse Resume Examples & Samples

Knowledge of UAS-NY assessment
Knowledge of Managed Long Term Care regulatory requirements
Previous Quality Improvement experience
Certification in UAS assessment

Clinical Review Nurse Resume Examples & Samples

5+ years of Clinical experience
2+ years of previous Managed Care experience
Proficiency with the use of mobile technology (Smartphone, wireless laptop, etc.)

Quality Review Nurse Resume Examples & Samples

Proficiency in all Microsoft Office applications, including Word and Excel
Working knowledge of computers, or a demonstrated technical aptitude and an ability to quickly learn new systems
Associate’s or Bachelor’s Degree in Business, Finance or a related field
Familiarity with medical terminology and/or ICD-9 codes

Medically Managed Bill Review Nurse Resume Examples & Samples

Licensed Practical Nurse.Skill
Has substantial understanding of the job and applies knowledge and skills to complete a wide range of tasks.Job Complexity
Works on assignments that are moderately difficult, requiring judgment in resolving issues or in making recommendations
Supervision
Normally receives little instruction on daily work, general instructions on newly introduced assignments.Experience
Typically requires a minimum of 2 - 4 years of related experience

Retrospective Review Nurse Resume Examples & Samples

3+ years of Acute Care experience
CPT experience / knowledge
Experience with Retrospective Reviews

Medically Managed Bill Review Nurse Resume Examples & Samples

LPN/LVN with two years clinical nursing experience
Knowledgeable in computer operations, including Windows operating system, data entry skills and 10-key capabilities
Knowledge of ICD-9 and CPT coding procedures
Must demonstrate the ability to understand state laws and utilization guidelines as they apply to bill review activity
Utilization review experience
ICD-9 and/or CPT coding experience
HFCA and UB billing knowledge
CPHM and/or coding credentials or eligible
Demonstrates knowledge and support of the philosophy, purpose and goals of the organization
Demonstrates basic problem solving skills to ensure early intervention and identification of those injuries which will benefit from medical case management or to identify questionable claims during the retrospective bill review process
Demonstrates basic knowledge of UR process
Demonstrates basic knowledge of ICD-9 coding
Demonstrates basic knowledge of HCFA billing and CPT and HCPCS coding
Demonstrates basic knowledge of UB billing, Primary Procedure codes, revenue codes and jurisdictional direction regarding use
Demonstrates basic knowledge of CCI edits
Review of complex HCFA bills to determine authorization, relation to injury and appropriateness of service
Review of complex UB bills to determine authorization, relation to injury and appropriateness of service
May refer high dollar bills to BR department for advanced negotiation as identified in negotiation protocol
Adapts to organizational changes with a professional and positive approach
Demonstrate the ability to manage time effectively and efficiently
May include advanced bill negotiation
Minimum Nurse review queue processing standards per Policy MMBR-105
Assists in completing bills within five (5) business days of receipt into the nurse review queue and be accountable for assigned customer(s) results, productivity and quality
Maintains updated knowledge of HCFA and CPT coding and applicable jurisdictional guidelines
Maintains updated knowledge of UB billing, Primary Procedure codes, Revenue codes and applicable jurisdictional guidelines
Performs nurse review functions with error rate of < 10%
Participates in departmental projects and meetings with 80% minimum attendance at meetings
Acknowledges and adheres to Bunch and Associates policies and procedures

Retrospective Review Nurse Resume Examples & Samples

Current RN license in state where employed
U.S. Citizenship is required based on our DOD contract
3 years of experience in clinical RN setting
UR/QM experience
Certification in Managed Care Nursing
HIAA certification

Clinical Review Nurse Resume Examples & Samples

Patient-oriented
Experience with medical or chart audit reviews
2 years' experience in a home care environment or as a staff nurse in an acute, sub-acute or long-term care (LTC) setting or managed long-term care plan
Experience with Geriatrics, Medical-Surgical Nursing, Case Management or Discharge Planning

Documentation / Chart Review Nurse Resume Examples & Samples

1+ year of Nursing experience in a Home Care setting
Experience with Allscripts EMR
Documentation Review experience

Preservice Review Nurse Resume Examples & Samples

Perform utilization; pre-service and concurrent review using Milliman criteria
Approve bed days for inpatient cases when applicable
Arrange alternative care services; Contact and maintain communication with acute long term care, acute rehabilitation or skilled nursing facilities to move patients through the care continuum
Gather clinical information to assess and expedite care needs
Candidates must reside within a 60 miles radius from our Kingston, NY office to be considered for this role
Current, unrestricted RN license in the state of residence
3+ years recent hands on clinical experience in an inpatient / acute setting
Proficient with Microsoft Word to create, edit, save and send documents
Ability to navigate a Windows environment, Microsoft Outlook and conduct Internet searches
Utilization management, prior authorization or case management experience
Working knowledge of Milliman and / or InterQual
Experience working with appeals and denials

Utiltization Review Nurse Resume Examples & Samples

Applies clinical review criteria, guidelines, and screens in determining the medical necessity of health care services against the clinical data provided
Consults with physician when reviews do not meet clinical review criteria,
Prefer at least 3-4 years of clinical experience
Ability to effectively manage multiple shifting priorities
Able to meet deadlines
Thrives in a team environment
Must be able to work congenially with a wide variety of individuals
Proficiency Legends

Supervisor, Concurrent Review Nurse Resume Examples & Samples

Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
Conduct discharge planning
Direct care to participating network providers
Serve as a subject matter expert for questions or issues for other Concurrent Review Nurses and Prior Authorization Nurses

RN, Concurrent Review Nurse Resume Examples & Samples

Current unrestricted license, as a registered nurse, in state(s) of practice is required
Bachelor of Science in Nursing required; Masters of Sciencein Nursing preferred. Will accept equivalent experience in lieu of degree if the candidate obtains his/her BSN within 3 years post hire
Minimum 3 years clinical experience as Registered Nurse (RN) required
Minimum 5 years utilization management experience preferred
Demonstrated experience in utilization management, facility concurrent review, discharge planning, and transfer coordination
Experience with Indicia (formally Milliman Care Guidelines) authorization criteria preferred
Performs initial, concurrent and retrospective reviews on all inpatient, facility and appropriate home health services
Ensures appropriate placement and monitors level and quality of care
Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs
In conjunction with, and under the supervision of physicians, evaluates and provides feed-back to treating physicians regarding a member's discharge plans and available covered services including identifying alternative levels of care that may be covered
Monitors all utilization reports to assure compliance with reporting and turnaround times
Addresses care issues with Director of Care Management, Physician Advisor and Chief Medical Officer/Medical Director as appropriate
Coordinates an interdisciplinary approach to support continuity of care. Provides utilization management, transfer coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for members
Consults with physicians, health care providers and outside agencies regarding continued care/treatment or hospitalization
Review per diem patients daily for medical necessity to ensure reimbursement
Actively participates in the discussion and notification processes that result from the clinical utilization reviews with the facilities
Reviews any service denials and gathers necessary supporting documentation from chart audits and follows up according to procedures
Prepares CMS compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation
Assists in the identification and reporting of Potential Quality of Care concerns
Responsible for assuring these issues are reported to the Quality Improvement Department
Provides backup for Case Manager
Work as an interdisciplinary team member within Divisional Care Management departments
Other duties as assigned within Population Health Care Management
Understands and self-manages to support facility/CIN-level success goals, including improvements in quality, cost of care and member experience for the facility/CIN’s population
Identifies opportunities for improvement (at individual, clinic and facility/CIN levels) and actively works with healthcare and facility/CIN team to correct or improve results

Retrospective Review Nurse Resume Examples & Samples

Communicates with coordinators and Medical Directors, the case disposition of ER PLP reconsiderations
Reviews medical records against PLP guidelines and recommends a case disposition
Applies clinical knowledge in the assessment, evaluation and interpretation of clinical notes submitted by the provider
Evaluates the medical record so that patient age, time of day, severity of injury, availability of medical resources, etc. are considered when adjudicating the PLP case
Documents the clinical aspects of the case and the reasoning for the determination outcome in numerous databases
When appropriate, seeks additional clinical advice and recommendations to properly adjudicate the PLP case
Serves in all phases of the reconsideration process from preloading of cases, case disposition and letter generation. Prepares cases for scanning and archiving
Verifies eligibility, timeliness and record completeness of ER PLP cases and follows up with the provider as necessary
Electronically enters claim detail information in organization applications including Sidewinder and documents receipt, disposition and other noteworthy aspects of the cases in the application
Assists in resolving provider issues through the use of organizational databases and reports, communication with internal departments such as Claims and Appeals and contact/communication with ER PLP clinical coordinators and Medical Directors
Participates in process development and testing of new process implementation
Evaluates data input and output for accuracy and ensures compliance with data integrity and corporate compliance directives
Participates in ad hoc projects that require clinical evaluation of medical records as directed by the Manager and/or Director
Identifies misuse of ER utilization and resources and communicates with Manager/Director/Medical Director as needed
Ensures timely processing and review of reconsiderations to meet departmental goals and state specific benchmarks for timeliness
Performs other duties as directed by the Manager and/or Director

Preservice Review Nurse Resume Examples & Samples

Responsible for performing pre-service clinical coverage review of services (predetermination reviews), using applicable benefit plan documents, evidence-based medical policy and nationally recognized clinical guidelines and criteria
Responsible for managing clinical Out of Network referral requests
Obtain additional clinical information from treating physicians and other healthcare professionals as needed
3+ years recent hands on clinical experience in an inpatient, physician practice and / or acute setting
Proficient with Microsoft Word to create, edit, save and send documents. Ability to navigate a Windows environment, Microsoft Outlook and conduct Internet searches

Retrospective Review Nurse Resume Examples & Samples

Follows up on obtaining missing medical records prior to deadlines
Identifies and/or clarifies inpatient vs. outpatient stays, discharge times and other vital information that will ensure the accuracy of the authorization request
Actively participates in team meetings to identify issues, research problems and develop/implement solutions; work effectively with other internal departments for problem identification and resolution

Second Level Review Nurse Resume Examples & Samples

Maintain current knowledge of the TRICARE/CHAMPUS program
Conduct reviews for purpose of validation on records previously reviewed by Maximus or on records submitted for reconsideration/appeal or prepayment review
Review records for quality and report findings on a quarterly basis or maintain records and produce reports
Work with Program Integrity and/or Government Affairs on cases with potential medical findings and/or congressional issues
Assist with special projects as identified by Manager
Minimum of 3 years’ experience in varied clinical setting
Good communication skills, verbal and written
Certification in managed care nursing
Utilization Review or Quality Management experience
Interqual knowledge
Working knowledge of ICD-9, HCPCS, DRG use

Utilization Claims Review Nurse Resume Examples & Samples

Computer experience necessary
Problem solving abilities
Work cooperatively, positively, and collaboratively in an interdisciplinary team

Retro Review Nurse Resume Examples & Samples

Claim reviews are completed in a timely manner
Appropriate level of care is confirmed
Authorizations updated in timely manner
Members are in appropriate level of care according to criteria
Documentation is complete and accurate so claim is reimbursed in timely manner
Knowledge of CPT and HCPCS codes
Work respectfully and positively with members
Ability to manage multiple tasks and prioritize work tasks to adhere to deadlines and identified time frames

Clinical Claims Review Nurse Resume Examples & Samples

Review clinical information for accuracy
Complete review within established time frames
Update information in electronic claims system
Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of claim
Initiate interdepartmental coordination to ensure quality and timely care for members
Review air, ambulance and ground transportation claims
Identify member’s Third Party Liability coverage
Claims are paid within the identified time frame per contractual requirements
Interdepartmental communication occurs to request and obtain additional information to complete claim review
Members are identified with Third Party Liability coverage
Knowledge of Medicare and Medicaid regulations and guidelines
Knowledge of ICD-9/ICD-10 (when applicable)

SIU Review Nurse Resume Examples & Samples

Registered Nurse with current RN license in good standing required. Minimum of 2 years recent and related experience in medical terminology, coding and claims processing
Advanced knowledge of managed care operations, as well as advanced clinical knowledge and skills
Minimum of 1 year recent and related experience in conducting and interpreting quantitative/qualitative analysis

Clinical Review Nurse Resume Examples & Samples

Apply understanding of utilization management as it relates to the continuum of care
Assist in clearing claims for billing as indicated
Assist in determining system-wide care management needs through investigation of retrospective denials or revenue cycle audits, and identification of root cause
Assist the Health Services Division in responding to billing inquiries/complaints, which require a clinical understanding
Collaborate with other departments to ensure all information to support services rendered is identified
Collaborate with physician leadership as warranted in preparation of appeal/clinical review responses
Complete timely and accurate appeals and/or clinical reviews using established processes
Coordinate payor audits, conduct post-audit to validate auditor findings and identify previously unbilled services
Formulate written appeal letter or clinical summary as appropriate, incorporating supportive documentation. (i.e. medical criteria, state regulations, etc)
Identify and assign a root cause to each case to ensure denial reasons are tracked
Maintain collaborative relationships with utilization management and appeal departments at payor organizations
Maintain current knowledge of regulatory guidelines related to retrospective appeals and clinical reviews
Monitor and evaluate for areas of process improvement related to the retrospective appeal/3rd party audit process to ensure regulatory compliance
Negotiate agreement with payor regarding final outcome
Perform clinical review for cases including but not limited to those referred for retrospective appeal, 3rd party audit, or validation of services rendered
Serve as a clinical liaison between revenue cycle staff, utilization review, payors and physicians when indicated
BSN or Bachelors degree preferred
Five years clinical experience required
Two years payor or care management experience preferred
Three to five years in a health care financial environment preferred
Knowledge of medical necessity criteria (InterQual) preferred
Knowledge of CPT-4 and Revenue Coding is strongly preferred
Prior appeal/grievance experience preferred
Knowledge of payer reimbursement structure preferred
Negotiation skills

Clinical Review Nurse Resume Examples & Samples

3 years of experience in a healthcare setting
2 years of experience in hospital or insurance related utilization review
Working knowledge of financial aspects of third-party payors and reimbursement
Effective decision-making/problem-solving skills
Demonstration of creativity in problem-solving
Must possess above-average computer skills
Provides clinical information to insurance companies as needed for completion of pre-certification process as noted in Children's Healthcare of Atlanta utilization management plan
Evaluates all patients, including critical care, for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria, and third-party information within 24 hours or next business day
Initiates and facilitates physician communications relative to utilization review process when indicated without prompting and follows up to ensure completion, including peer-to-peer reviews, securing admission orders, and reporting quality issues
Reviews concurrently all inpatients, including critical care, every three days or sooner if payor requests, including information regarding patient's medical condition, intensity of services being utilized, treatment plan, and established review criteria
Ensures all pertinent information is documented into various systems for utilization review process
Gathers and reviews relevant medical information and documents utilization review process outcome based on system accepted utilization criteria on the accepted current review forms and in computer systems
Supports organizational efforts to ensure accurate capture of admission status and level of care using Epic and escalating cases for status change where necessary
Refers denied cases to appropriate personnel and provides assistance and/or clinical support to aid in appeal process
Serves as resource to Case Management for facilitation of patients moving to appropriate level of care and notifying when patients no longer meet medical necessity to aid in discharge planning
Meets productivity (10-12 reviews/day) and quality assurance (95%) standards and demonstrates utilization review proficiency with the successful completion and passing of McKesson Interrater Reliability testing
Attends all required onsite, telephonic, and mandatory department meetings
Participates in department activities to help promote utilization review process, aids in denial prevention, and serves as resource to peers and team members

Rn Onsite Review Nurse Resume Examples & Samples

Conduct admission review and assist in discharge planning as needed
Active RN license in NC without restrictions
Minimum 2 years clinical experience in an acute care setting
Good communication and organization skills
Must have accessibility to high speed DSL or Cable modem for a home office (Satellite internet service is NOT allowed for this role); and recommended speed for optimal performance from Humana At Home's systems is 10Mx1M
TB screen required

Rn-review Nurse Resume Examples & Samples

Knowledge of DME / Ortho / Sports medicine products criteria desirable
Computer knowledge; data entry skills, and keyboard at 35 words per minute
Ability to work independently utilizing critical thinking and analytical skills
Must have strong written and verbal customer service communications skills
Must be self-motivated, able to multitask and strong sense of teamwork
Reviewer or prior approval experience preferred
RN with current license required
Three to five years of recent clinical experience
Three to five years of Commercial, UM/UR, Case Manager or Home Health Nursing experience preferred
Experience in hospital reviews and durable medical equipment desirable

Prior Authorization Review Nurse Resume Examples & Samples

Must have knowledge of computers and basic applications
Must be able to sit at a desk to work all day
Need to be able to make independent decisions using policy guidelines
Medicaid experience preferred but not required
Prior authorization experience preferred but not required
Knowledge of durable medical equipment preferred but not required

Rn-onsite Review Nurse Resume Examples & Samples

Active RN license in NC
Experience with Interqual or Milliman
Prior clinical experience in an acute care, skilled or rehabilitation clinical setting

Review Nurse Resume Examples & Samples

Responsible for investigating and processing medical necessity appeals requests from members and providers
Conducts investigations and reviews of member and provider medical necessity appeals
Reviews prospective, inpatient, or retrospective medical records of denied services for medical necessity
Summarizes medical information for medical director
Prepares recommendations to either uphold or deny appeals
Must have active RN license in the state of California with no restrictions
AS/BS Nursing preferred
2+ Managed care in a healthcare setting, or combination of education and experience
Competitive pay

Retrospective Review Nurse Resume Examples & Samples

Minimum of 1 year of general nursing experience
Ability to review and interpret treatment plans
Ability to define problems, collect/interpret data, establish facts, draw valid conclusions and process work to completion. Knowledge of medical terminology and/or experience with CPT and ICD-9 coding
Knowledge of electronic billing systems

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