Rn-utilization Review Resume Samples
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Rn-utilization Review Resume Samples
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RW
R Wolf
River
Wolf
7522 Gerlach Run
Los Angeles
CA
+1 (555) 907 5539
7522 Gerlach Run
Los Angeles
CA
Phone
p
+1 (555) 907 5539
Experience
Experience
New York, NY
Utilization Review RN
New York, NY
Crist-Larkin
New York, NY
Utilization Review RN
- Works in conjunction with Clinical Documentation Improvement nurses to identify the Working DRG for patients admitted as inpatients and ensure the Working DRG is entered into the Cerner UM Module in order to calculate the GMLOS
- Ensures prior authorizations are entered into the UM Module for those services requiring prior authorization from the patient’s third-party payer. Enters approved hospital days into the UM Module when received by the patient’s payer
- Participates in daily departmental planning meetings and meets with the clinical team to guide the patient’s discharge plan
- Refers to the Utilization Review Physician Advisor all cases that do not meet established guidelines for admission or continued stay consistent with the arrangement with the Physician Advisor
- Performs concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines
- Licensed as a Registered Nurse
- Knowledge of Medicare and Medicaid payment rules, policies and regulations
Boston, MA
Rn-utilization Review
Boston, MA
Douglas-Robel
Boston, MA
Rn-utilization Review
- At the request of third party payers, Provides concurrent and retrospective reviews in an effort to extend authorized days and ensure reimbursement due for services provided
- Serves as resource for case management and social service professionals with regard to managed care contract interpretation
- Provides information to CIC staff regarding medical record coding
- Educates staff with updates in Medicare Medicaid and Managed care initiatives
- Initiates and Coordinates orientation for all new case management professionals to the department
- Completes quality monitoring of the case management professionals documentation to the department standards on a weekly basis using a tool designated to measure compliance to standards of practice. Provides feedback to leadership and individuals in a professional manner
- Completes data collection, tracks and trends information on denials related to medical necessity. Identifies performance improvement opportunities and collaborates with all levels of staff to develop and implement process improvements
present
San Francisco, CA
RN Telephonic Utilization Review
San Francisco, CA
Satterfield LLC
present
San Francisco, CA
RN Telephonic Utilization Review
present
- Collaborate with other health care givers in reviewing actual and proposed medical care
- Manage network participation and transfers to alternative levels of care using your knowledge of benefit plan design
- Communicate with providers regarding necessary adjustments to proposed care plans based on established criteria
- Active RN license in the state of TX with no restrictions
- Reside in the state of TX
- History of meeting or exceeding productivity metrics
- Manage network participation, care with specialty networks, care with DME providers and transfers to alternative levels of care using your knowledge of benefit plan design
Education
Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
University of California, Berkeley
Bachelor’s Degree in Nursing
Skills
Skills
- Working knowledge of Microsoft Office Suite, including Excel, and ability to develop and mine databases
- Ability to interact professionally with case management staff, physicians and payers
- Knowledge of case management, working of Medicare, Medicaid and private insurance
- Demonstrates a commitment to service, organization values and professionalism through appropriate conduct and demeanor at all times
- Basic understanding of computer application
- Case Management experience nice to have
- Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues
- Extensive clinical expertise - ICU, Medical
- Adheres to and exhibits our core values
15 Rn-utilization Review resume templates
Read our complete resume writing guides
1
Utilization Review Rn-northeast Region Resume Examples & Samples
- Manage network participation,
- Analyze clinical protocols and identify potentially unnecessary services and care delivery settings, and recommend alternatives if appropriate by analyzing
- Utilize screening criteria to examine clinical programs and identify members for specific case management and / or disease management activities or interventions
- Experience with chart review for medical necessity
- Insurance or managed care experience
- Medicare/Medicaid Experience a plus
- Previous experience in utilization review
- Up to 5% travel for potential training purpose
2
Utilization Review RN Resume Examples & Samples
- Establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of all hospital admissions. Communicates patient admission status information to business operations staff in a timely manner such that patients obtain timely and appropriate care in the hospital setting as required by their clinical conditions
- Assure the RN Care Coordinator assigned to the patient is aware of the self-pay status of patients and make necessary referrals to financial counselors and/or hospital’s contracted financial counseling agencies, members of the healthcare team regarding target length of stay (LOS), acute care criteria, pay requirements, resource utilization, and care options to meet patient needs
- Develops and maintains relationships with third-party payers necessary to coordinate the appropriate utilization of hospital resources and meet the clinical needs of assigned patients
- Refers to the Utilization Review Physician Advisor all cases that do not meet established guidelines for admission or continued stay consistent with the arrangement with the Physician Advisor
- Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and timely discharge. Tracks and reports trends of inappropriate utilization of resources to the Utilization Review Manager
- Licensed as a Registered Nurse
- Minimum of 3 years nursing experience prior to care coordination required
- Ability to evaluate medical records and other health care data
- Ability to exercise good judgment and tact in relating to third-party payers, physicians and patients
- Ability to maintain confidentiality in all tasks performed
3
RN Telephonic Utilization Review Resume Examples & Samples
- Minumum 3 years adult acute care experience
- Strong assessment skills and proven ability using critical thinking to determine appropriateness of services
- Experience utilization criteria such as Interqual or Milliman
- Strong computer skills, ability to learn new programs quickly
4
RN Telephonic Utilization Review Post-acute Resume Examples & Samples
- Collaborate with other health care givers in reviewing actual and proposed medical care
- Manage network participation and transfers to alternative levels of care using your knowledge of benefit plan design
- Communicate with providers regarding necessary adjustments to proposed care plans based on established criteria
- Strong assessment skills
- Excellend computer and communication skills
5
Rn-utilization Review Resume Examples & Samples
- At the request of third party payers, Provides concurrent and retrospective reviews in an effort to extend authorized days and ensure reimbursement due for services provided
- Subject matter expert regarding clinical appropriateness and level of care for CIC staff as well as Patient Access Services and Patient Financial Services staff. Reviews on referral cases to assist in determination of clinical appropriateness for level of care and Medicare/Medicaid and Managed Care related issues
- Reviews all patient documentation in response to letters of denial for reimbursement. Assess individual situations and makes appropriate referrals to physician advisor. Implements appeal process
- Serves as resource for case management and social service professionals with regard to managed care contract interpretation
- Provides information to CIC staff regarding medical record coding
- Educates staff with updates in Medicare Medicaid and Managed care initiatives
- Initiates and Coordinates orientation for all new case management professionals to the department
- Completes quality monitoring of the case management professionals documentation to the department standards on a weekly basis using a tool designated to measure compliance to standards of practice. Provides feedback to leadership and individuals in a professional manner
- Completes data collection, tracks and trends information on denials related to medical necessity. Identifies performance improvement opportunities and collaborates with all levels of staff to develop and implement process improvements
- Completes data collection, analysis and project development for Medicare/Medicaid and managed care initiatives. Identifies performance improvement opportunities and collaborates with all levels of staff to develop and implement process improvements
- Knowledge of case management, working of Medicare, Medicaid and private insurance
- Ability to interact professionally with case management staff, physicians and payers
- Working knowledge of Microsoft Office Suite, including Excel, and ability to develop and mine databases
- Extensive clinical expertise - ICU, Medical
- Case Management experience nice to have
6
Weekend RN Utilization Review Resume Examples & Samples
- Examine clinical programs information to identify members for specific disease management activities or interventions by utilizing established screening criteria
- Available to work Thurs - Sun each week
- Strong assessment skills and familiarity conducting reviews for medical necessity and appropriate level of care
- Good communication and computer skills
7
Utilization Review Rn-post-acute Team-central Region Resume Examples & Samples
- Working on UM cases for skilled nursing facilities, transition of care, skilled nursing and acute
- Prior clinical experience preferably in post acute care
- Previous case management, utilization review and/or discharge planning experience as a nurse
8
Utilization Review RN Resume Examples & Samples
- 3+ years nursing experience prior to care coordination required
- Written and verbal communication skills
- Work as a part of a team
- Maintain confidentiality in all tasks performed
- Deal with problems involving several concrete variables in standardized situations
9
RN Utilization Review Manager Resume Examples & Samples
- Knowledge of Medicaid and Medicare healthcare practices and policies
- Knowledge of Medicare regulations related to utilization management turnaround times and billing rules
- High level of proficiency using InterQual and the ability to provide education and guidance to staff
- Strong written and verbal communication skills in order to effectively communicate with members, physicians, providers, plan leadership and staff members
10
RN Dir Utilization Review Days Resume Examples & Samples
- Bachelor's degree in nursing, health services administration or equivalent experience
- RN with extensive and varied clinical experience
- MA or MS or applicable graduate degree preferred
11
RN Utilization Review PRN Resume Examples & Samples
- Perform admission InterQual as per Plan contract or within 24 hours on all Non-Medicare Inpatients and document in Midas
- Ensure the patient’s status is correct (Inpatient vs Outpatient)
- Review concurrent denials and work with facility, physician and Plan to overturn the denial, document in Midas Denied Days screens
- Communicate denial status to the facility and physician
- Follow X-Code process as per HCA policy
- Communicate with physicians regarding patient status
12
Utilization Review Rn-weekends Resume Examples & Samples
- Prior clinical experience preferably in an acute care clinical setting
- Comfortable with Microsoft Office products including Word, Outlook and Excel
- Desire and ability to work at home in a safe and private environment, as outlined in WAH policy
- Positive disposition
- Previous experience with Milliman (MCG)
- Previous virtual work experience
13
Rn-utilization Review Specialist Resume Examples & Samples
- The Utilization Review (UR) Specialist has well-developed knowledge and skills in areas of utilization management (UM), medical necessity, and patient status determination. This individual supports the UM program by developing and/or maintaining effective and efficient processes for determining the appropriate admission status based on the regulatory and reimbursement requirements of various commercial and government payers
- This individual is responsible for performing a variety of concurrent and retrospective UM-related reviews and functions and for ensuring that appropriate data is tracked, evaluated, and reported. This individual monitors the effectiveness/outcomes of the UM program, identifying and applying appropriate metrics, evaluating the data, reporting results to various audiences, and designing and implementing process improvement projects as needed
- This individual identifies, develops, and provides orientation, training, and competency development for appropriate staff and colleagues on an ongoing basis. This individual leads and/or actively participates in process improvement initiatives, working with a variety of departments and multi-disciplinary staff
- This individual maintains current and accurate knowledge regarding commercial and government payers and Joint Commission regulations/guidelines/criteria related to UM. This role is responsible for ensuring that the UM program maintains documented, up-to-date policies and procedures and ensures and that all UM key processes have valid outcome measures that are monitored for compliance and reported to a variety of audiences
- The UR Specialist effectively and efficiently manages a diverse workload in a fast-paced, rapidly-changing regulatory environment. The UR Specialist is a member of and provides support to the hospital’s UR Committee. He/she collaborates with multiple leaders at various levels throughout UW Health, including directors and vice presidents, for the purpose of supporting and improving the UM program. The UR Specialist is responsible to the Medicare/Medicaid UR Program Manager
- Three (3) years relevant clinical nursing experience
- Recent experience as an inpatient or outpatient utilization review nurse or UM coordinator
- RN license in the State you will be working from
- Excellent interpersonal communication, problem-solving, and conflict resolution skills
- Computer skills in word processing, database management, and spreadsheet desirable
- Knowledge in areas of: Medicare and Medicaid UM regulations, McKesson InterQual, Medicare Inpatient Only List, RAC, QIO, MAC, and Denial Management
14
Supervisor Utilization Management Review, RN Resume Examples & Samples
- Required Registered Nurse graduated from an accredited Diploma, Associate’s Degree or Bachelor’s Degree program required. (Master’s degree preferred)
- Required minimum 3-5 years progressively responsible experience in a clinical environment
- Required 1-2 years utilization management/case managment
- Required solid PC skills required (Word, Excel and PowerPoint); ability to analyze and interpret data
- Required 3 years of current and progressive supervisory level experiences to include team leader or charge nurse
- Required valid driver’s license required (and reliable transportation for requested offsite work related activities
- Highly Preferred knowledge of discharge planning, outpaient clinical reviews transition care
- Preferred Managed care or Commercial Insurance
15
Utilization Review RN Resume Examples & Samples
- Screens selected medical records in accordance with contractual agreements and departmental policies for appropriateness of admission; performing initial, continued stay, and retrospective reviews if applicable
- Submits initial reviews and updates using established criteria and communicates with payers as appropriate, using established processes
- Utilize established processes with the Physician Advisors to manage second level and peer to peer reviews
- Ensure patient status and levels of care are appropriate on admission and prior to discharge
- Makes timely contact with payers and provides information as appropriate
- Documents all utilization review outcomes and activities appropriately in the medical record
- Complies with all applicable payer, state and federal regulations as well as The Joint Commission requirements regarding Care Management and Utilization Review processes
- Acts as resource for and provides updates to the care management staff and care team for issues related to utilization review processes
- Engages providers with concerns regarding medical necessity and appropriateness of services
- Escalate concerns related to medical necessity and appropriateness of services to the Physician Advisors
- Works collaboratively with the Denials Specialist and Physician Advisors to manage retrospective appeals and documents according to established policy
16
Rn-utilization Review Resume Examples & Samples
- Reviews admissions and service requests within assigned unit for prospective, concurrent and retrospective medical necessity and/or compliance with reimbursement policy criteria. Provides case management and/or consultation for complex cases
- Assists departmental staff with issues related to coding, medical records/documentation, precertification, reimbursement and claim denials/appeals
- Three years of clinical experience required
- Previous case management, UR, billing, reimbursement and revenue cycle preferred
17
RN, Utilization Review Resume Examples & Samples
- Participates in designated committees and task forces according to the UM Program and at the direction of the Sr. Director of Medical Management. Coordinates with the utilization review, case management, discharge planning staff within network facilities
- Coordinates with Medical Director/Associate Medical Directors on case-specific issues
- Coordinates with Claims, Member Services, Grievance Coordinator and other operational departments regarding case management issues
- Conducts Utilization Management review for Inpatient, Outpatient, or Skilled Nursing cases
- Current license to practice as a Registered Nurse in the State of Ohio
- Minimum of 5-7 years of clinical nursing experience with at least 2 years' experience in utilization review, discharge planning, case management, or medical social work experience required. Nursing experience in an HMO insurance company setting
18
Rn-utilization Review Resume Examples & Samples
- Conducts admission review to assure that the hospitalization is warranted based on established criteria. Reviewing may be both concurrent or Post Discharge
- Carries out hospital programs and principles of utilization review in compliance with hospital policies and external regulatory agencies Peer Review Organization (PRO), Joint Commission, and multiple payer defined criteria for eligibility
- Engages in discussion with the Attending physician for clarification and/or status correction
- Engages second level physician review as indicated to support the appropriate status
- Ensures timely communication with Social Work staff for all concurrent status changes
- Administers Notice of Status Change to the patient/family when indicated. Provides education and information for the patient/family for clarification of the change
- Documents in the progress notes accurately to reflect the appropriate admission criteria and appropriate status along with any communications
- Ensures timely notification to Admitting of status of change or status discrepancies identified
- Reviews the records on admission for status orders present addressing CMS rules and guidelines around admission status
- Provides clinical information as requested from the insurance payer via telephone or fax in a timely manner to prevent technical denials
- Enters authorization, approvals and denials into the chart and communicates pertinent changes to Case Management
- Engages the attending physician to advocate and communicate via Peer to Peer Review for discussion with insurance for admission, continued stay or status when required
- Reviews denial letters/faxes received in and direct to Conifer CRC for appeals
- Collaborates in monitoring and addressing observation outliers and status discrepancies with HIM and Admitting
- Current licensure as a registered nurse of Iowa and five years clinical nursing experience. BSN or degree in healthcare related field preferred
- Basic understanding of computer application
- Knowledge of eligibility requirements for insurance coverage with respect to health care services: inpatient adult and child/adolescent, partial hospitalization, and Intensive Outpatient levels of care
- Demonstrated ability to manage complex management and clinical situations. Ability to work within a function independently exercising judgement to reach resolutions to issues
19
Utilization Review Rn-bradley Resume Examples & Samples
- Two years of relevant progressive work experience in clinical psychiatric healthcare preferred
- Strong professional, organizational, and interpersonal skills required for effective and creative leadership in working with all levels of the organization, including physicians, committees as well as patients and their families
- Ability to communicate with outside agencies, third party payors, and regulators
- Possess good analytical and problem solving skills
- Ability to work with computerized clinical information systems. Initiative, flexibility, integrity, and diplomacy
- Licensed Registered Nurse
20
RN Utilization Review Case Manager Resume Examples & Samples
- Educates patient, families and other members of the care team about the financial out of
- Communicates pertinent information to the appropriate members of the patient care team both effectively and professionally. Takes responsibility to identify and eliminate barriers to effective patient stay management and promotes improvements in work processes within department, hospital, and community
- Provides consultation to professional staff and physicians on level of care determinations, CMS regulations and payer specific guidelines. Accurately and completely documents clinical reviews in accordance with documentation standards, policies, procedures and/or guidelines
- Associates degree from an accredited RN program
- Current license to practice as registered nurse in the State of Ohio
- Minimum of 3-5 years recent clinical experience in an acute care setting, case management or utilization review experience
21
Acute Onsite Rn-utilization Review Resume Examples & Samples
- Prior clinical experience in an acute care setting
- Valid driver's license and/or dependable transportation necessary (variable by region)
- Previous Medicare Experience
- Strongly Prefer Previous experience in utilization review
22
Optum Field Based Utilization Review Rn-maricopa County Resume Examples & Samples
- Perform utilization management, utilization review, or concurrent review (on - site or telephonic inpatient care management)
- Determine medical appropriateness of inpatient and outpatient services following evaluation of medical guidelines and benefit determination
- Identify solutions to non - standard requests and problems
- Current, unrestricted RN license in the state of residence
- 3+ years of experience in an acute care setting
- Knowledge of utilization management, quality improvement, discharge planning with transitions of care
- MCG certification, if does not have certification, must obtain within 3 years of hire
- Experience working with Medicare members
- MCG utilization management experience
- Working knowledge of hospice and palliative care
- Graduate degree in related field
- Working knowledge of SNF & LTAC facilities
- Bachelor’s degree in nursing (BSN)
- Experience using EMR, utilization management and / or prior authorization systems
