Utilization Management Nurse Resume Samples
4.8
(93 votes) for
Utilization Management Nurse Resume Samples
The Guide To Resume Tailoring
Guide the recruiter to the conclusion that you are the best candidate for the utilization management nurse job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.
Craft your perfect resume by picking job responsibilities written by professional recruiters
Pick from the thousands of curated job responsibilities used by the leading companies
Tailor your resume & cover letter with wording that best fits for each job you apply
Resume Builder
Create a Resume in Minutes with Professional Resume Templates
CHOOSE THE BEST TEMPLATE
- Choose from 15 Leading Templates. No need to think about design details.
USE PRE-WRITTEN BULLET POINTS
- Select from thousands of pre-written bullet points.
SAVE YOUR DOCUMENTS IN PDF FILES
- Instantly download in PDF format or share a custom link.
RZ
R Zemlak
Rafael
Zemlak
91839 Dorian Mountain
Phoenix
AZ
+1 (555) 741 5501
91839 Dorian Mountain
Phoenix
AZ
Phone
p
+1 (555) 741 5501
Experience
Experience
San Francisco, CA
Utilization Management Nurse
San Francisco, CA
Simonis, Dach and Ullrich
San Francisco, CA
Utilization Management Nurse
- Supports the effective prevention and management of denials, including providing requested information as part of the appeal process
- Assists in the identification and reviewing of Potential Quality of Care concerns through concurrent review. Provides backup for Case Manager
- Perform utilization management, utilization review, or concurrent review (on-site of via telephone)
- Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops
- Plan, organize and prioritize assignments to comply with performance standards, corporate goals, and established timelines
- Work as an interdisciplinary team member within Medical Management and across all departments
- Provides clinical support to non-clinical Care Management Coordinators as relates to Prior Authorization requests
Boston, MA
Utilization Management Nurse Rn-telecommute
Boston, MA
Johnson, Ankunding and Gutmann
Boston, MA
Utilization Management Nurse Rn-telecommute
- Perform utilization management, utilization review, or concurrent review (on - site or telephonic inpatient care management)
- Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care management)
- Provide explanations and information to others on difficult issues
- Coach, provide feedback, and guide others
- Coach, provide feedback and guide others
- Work with minimal guidance; seeks guidance on only the most complex tasks
- Critical analysis of case manager UM submission with review of supporting tools
present
Houston, TX
Utilization Management Nurse Review Specialist
Houston, TX
Powlowski-Baumbach
present
Houston, TX
Utilization Management Nurse Review Specialist
present
- Develop and maintain pre-established review parameters under the direction of the Corizon Medical Director
- Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting
- Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management
- Respond to inquiries by provider/site employees relating to standards of care and best practices
- The UM nurse is responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice
- Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements
- Assist with the data collection and reporting related to the UM outpatient/inpatient process
Education
Education
Bachelor’s Degree in Related Field
Bachelor’s Degree in Related Field
Rowan University
Bachelor’s Degree in Related Field
Skills
Skills
- Ability to learn quickly and retain complex information
- Strong Utilization skills and knowledge
- Strong attention to detail
- Ability to be professional in all dealings within and outside the company
- Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum
- Identify appropriate providers and facilities throughout the continuum of care, ensuring that the care is cost effective and of high quality
- Capable of priority setting
- Excellent verbal and written communication skills
- Basic computer and data analysis skills
15 Utilization Management Nurse resume templates
Read our complete resume writing guides
1
Utilization Management Nurse Resume Examples & Samples
- Current New York RN license
- 1+ year of experience as a nurse in a hospital setting
- Knowledge of utilization review, evidence-based guidelines, and case management process
- Case management certification preferred
- Basic computer and data analysis skills
2
Rn-onsite Utilization Management Nurse Resume Examples & Samples
- This position requires travel to acute care facilities in Flagler County / St. Augustine, FL area. The rest is work at home
- Prior clinical experience preferably in an acute care clinical setting
- Previous experience in utilization management, discharge planning and/or medical case management
3
Onsite Utilization Management Nurse Liaison Resume Examples & Samples
- This is a patient facing role so a TB test is required if hired
- Education: Associate or Bachelor's degree in Nursing
- Experience with Milliman and Interqual a plus
4
Onsite Utilization Management Nurse Resume Examples & Samples
- Experience in telephonic and or onsite utilization management conducting concurrent review and discharge planning
- Excellent written and verbal communication skills particularly with providers and members
- Experience with CMS criteria, Milliman and/or InterQual
- Experience working with HMO's
5
Utilization Management Nurse Resume Examples & Samples
- 2+ years of Utilization Management experience
- Previous Managed Care experience
- Knowledge of Medicaid benefits
- Knowledge of Interqual / Milliman criteria
6
Utilization Management Nurse Resume Examples & Samples
- New Jersey State Registered Nurse or Licensed Practice Nurse
- Associate's or Bachelor’s degree
- 2-4 years previous Utilization Management/Concurrent Review experience in Managed Care
- 2 years of Medical/Surgical experience
- Systems knowledge – Medical Management Systems
- PC proficiency: MS Office (Word & Excel)
7
Acute Utilization Management Nurse Resume Examples & Samples
- Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
- Ability to be licensed in multiple states without restrictions
- Valid drivers license and/or dependable transportation necessary (variable by region)
8
Utilization Management Nurse for the WI Sub-acute Team Resume Examples & Samples
- Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
- Prior experience working in a Skilled Nursing Facility (SNF) a plus
- Previous experience in utilization management, case management, discharge planning and/or home health or rehab
9
Utilization Management Nurse Resume Examples & Samples
- Associate’s or Bachelor’s Degree (or higher) in Nursing and/or a Health related field OR accredited diploma Nursing school
- Microsoft Office/Suite proficient (Word, Outlook, etc.)
- Solid analytical, critical thinking and problem solving skills
- Working knowledge of principles of Utilization Management
- Basic knowledge of Healthcare Contracts and Benefit Eligibility requirements
10
Utilization Management Nurse Resume Examples & Samples
- 2+ years of Acute Clinical Care experience
- Current, unrestricted FL Registered nurse (RN) license
- Previous Utilization Management experience in a Managed Care setting
- Experience using nationally accepted criteria (Interqual, Milliman, etc.)
11
Utilization Management Nurse RN Resume Examples & Samples
- Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care, skilled nursing facility, long term care facility, acute rehabilitation)
- Provide explanations and information to others on difficult issues
- Coach, provide feedback, and guide others
- Utilization Management / Utilization Review experience
- Case Management experience
- Knowledge of MCG Criteria
12
Utilization Management Nurse Resume Examples & Samples
- Strong Utilization skills and knowledge
- 2+ years of managed care experience
- 2+ years of clinical care experience
13
Rn-utilization Management Nurse Resume Examples & Samples
- Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
- Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria
- Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
- Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
- Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times
- Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member
- May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
- Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department
- Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
- Documents rate negotiation accurately for proper claims adjudication
- Identify and refer potential cases to Disease Management and Case Management
- Current RN license, applicable for practice in the applicable state
- 2 years of experience in managed care OR 5 years of nursing experience
- Strong problem solving and analytical skills
- Proficient in PC software computer skills
- Excellent communication skills both verbal and written skills
- Ability to interact productively with individuals and with multidisciplinary teams
- Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
- Previous Prior Authorization experience
- Utilization Review/Management experience
- ICD-9, CPT coding knowledge/experience
- InterQual or Milliman Knowledge/experience
14
Tricare Inpatient Utilization Management Nurse Resume Examples & Samples
- Performing care management activities to ensure that patients move through the continuum of care efficiently and safely
- Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan
- Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate
- Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources
- Referring patients to disease management or case management programs
- Assisting with the development of treatment plans
- Works with minimal guidance; seeks guidance on only the most complex tasks
- Works with less structured, more complex issues
- 3 years of clinical experience in an inpatient/acute setting
- Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment
- United States Citizenship
- Ability to obtain favorable adjudication following submission of Department of Defense eQuip Form SF86
- Knowledge of or experience with Milliman Care Guidelines
- Experience in discharge planning or chart review
15
Utilization Management Nurse Resume Examples & Samples
- 2+ years of experience in a Hospital setting
- Acute or Direct Care experience
- Experience as a Case Manager, Care Coordinator, Concurrent Review nurse, Utilization Review Nurse, or Discharge Planner
- Prior experience with EMRs, Case Management, Utilization / Concurrent Review, Prior Authorization, Care Coordination, & Discharge Planning software tools
- Basic knowledge of Health Care Contracts, Benefit Eligibility requirements, Hospital Structure and Payment Systems
- Working knowledge of Milliman/MCG/CareWebQ
16
Utilization Management Nurse Resume Examples & Samples
- 3 years of current Pediatric Registered Nurse experience
- Knowledge of Managed Care guidelines and medical insurance operations
- Bachelors of Nursing Degreed
17
Utilization Management Nurse Resume Examples & Samples
- Experience as a Case Manager, Care Coordinator, Concurrent Review nurse, Utilization Review Nurse, and/or Discharge Planner
- Basic knowledge of Healthcare Contracts, Benefit Eligibility requirements, Hospital structure and Payment Systems
- Working knowledge of Milliman / MCG / CareWebQI
- Prior experience with EMRs, Case Management, Utilization / Concurrent Review, prior Authorization, Care Coordination, and Discharge Planning software tools
18
Utilization Management Nurse Rn-telecommute Resume Examples & Samples
- Identify solutions to non - standard requests and problems
- 3+ years of experience in an acute care setting
- Knowledge of utilization management, quality improvement, discharge planning with transitions of care
- Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
- MCG certification, if does not have certification, must obtain within 3 months of hire
- Independent problem identification / resolution and decision making skills
- Able to prioritize, plan, and handle multiple tasks / demands simultaneously
- 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
- Experience using EMR, utilization management and / or prior authorization systems
19
Utilization Management Nurse Resume Examples & Samples
- Performs concurrent and retrospective reviews on all facility (hospital, skilled nursing facility, and acute rehabilitation) and appropriate home health services. 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. Evaluates and provides feedback to member’s providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate
- As part of the hospital prior authorization process, responsible for determining “observational” vs. “acute inpatient” status
- Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning
- Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds
- Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation
- Maintains accurate records of all communications
- Provides clinical support to non-clinical Care Management Coordinators as relates to Prior Authorization requests
- Monitors utilization reports to assure compliance with reporting and turnaround times
- Addresses care issues with Manager, Vice President and Chief Medical Officer/Medical Director as appropriate
- Coordinates an interdisciplinary approach to support continuity of care
- Provides utilization management, transition coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for providers and members
- Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation
- Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum
- Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies
- Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refers members for case Management accordingly
- Assists in the identification and reviewing of Potential Quality of Care concerns through concurrent review. Provides backup for Case Manager
- Work as an interdisciplinary team member within Medical Management and across all departments
- Provide back up for other members of the Medical Management team when needed
- Minimum 3 years clinical experience as RN or LPN required
- Minimum 5 years managed care or equivalent health plan experience preferred
- Demonstrated experience in health plan utilization management, facility concurrent review (hospital, skilled nursing facility, acute rehabilitation), discharge planning, and transfer coordination required
- Medicare Advantage experience preferred
- Experience with InterQual or Milliman authorization criteria required
- Excellent computer skills and ability to learn new systems required
- Strong attention to detail, organizational skills and interpersonal skills required
- Demonstrated ability to problem solve and manage professional relationships
20
Utilization Management Nurse Resume Examples & Samples
- Conduct recertification, and extensions of utilization review services which may include determinations for inpatient and outpatient admissions, physical, occupational, or chiropractic therapy treatments, diagnostic testing, etc., using nationally recognized criteria and personal clinical experience and medical knowledge
- Initiate referrals to Peer Review Services appropriately, and coordinate the services to support the utilization review. Ensure that peer review decisions are communicated within 1-2 business days
- Perform Utilization Management services within established clinical, productivity, phone and URAC standards. This includes ensuring that an Utilization Management determination is communicated to the provider within two business days of receipt of the medical information or as determined by Worker's Compensation law
- 3+ Years of relevant nursing experience
- Current nursing registration required
- Basic knowledge of states workers' compensation laws, disability management and utilization product review preferred
- Strong communication and interpersonal skills in order to receive and/or exchange information with healthcare providers, vendors, customers/injured workers, regulatory agencies, and legal professionals
21
Utilization Management Nurse Resume Examples & Samples
- Ability to work independently and be a problem solver under general instructions and with a team
- Experience working in a skilled nursing facility a plus
- Experience having to navigate multiple electronic medical record (EMR) systems a plus
22
Utilization Management Nurse Resume Examples & Samples
- Reviews charts and analyzes clinical record documentation
- Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff
- Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. Prepares monthly performance reports
- Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and other clinical staff
- Provides training, interpretation and support for QI Clinical Reviewer staff
- Responsible for auditing as well as validating internal audit results and/or corrective action plans
23
Utilization Management Nurse Resume Examples & Samples
- Two (2) years managed care experience in UM/CM Department, preferred
- Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred
- ICD-9 and CPT coding experience a plus
- Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
- Minimum Education: LVN
- 2 Years Health Plan Utilization Review or equivalent
- Preferred Experience: 5 years Health Plan Utilization Review
- 5 years Acute Care experience with 1 year ICU / ER
- Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments
- Office Work Environment
24
Utilization Management Nurse Associate Resume Examples & Samples
- Licensed Nurse, LPN or RN (RN is preferred)
- 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years (Required)
- Managed Care experience (preferred)
- Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel Excellent verbal/written communication skills
- Able to work independently in a virtual environment - and adjust to change
25
Senior Utilization Management Nurse RN Resume Examples & Samples
- Ability to work in a Matrix environment with little to no direction
- Identify solutions to non-standard requests and problems
- Work with minimal guidance; seeks guidance on only the most complex tasks
- Experience developing; implementing and executing Utilization Management programs, work plans and program descriptions
- Prepare documentation and oversee all Utilization Management committees
- Delaware RN license
- 3 or more years of Managed Care and / or Clinical experience
- Ability to create, edit, save and send documents utilizing Microsoft Word. Ability to navigate a Windows environment and other computer based programs
- Prior-authorization experience
- Utilization Management experience
- Acute care or Managed care Case management and / or Utilization management experience
- Knowledge of Milliman Criteria and Interqual Criteria
26
Utilization Management Nurse Consultant Resume Examples & Samples
- Licensed Registered Nurse required
- 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas
- Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel
- Excellent verbal/written communication skills
- Able to work independently in a virtual environment and adjust to change
27
Utilization Management Nurse Resume Examples & Samples
- Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures
- Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms
- In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care
- Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria
- Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence
- Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis
- Maintains an active work load in accordance with performance standards
- Works with community agencies as appropriate
- Participates in network development including identification and recruitment of quality providers as needed
- Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner
- Provides coverage of Nurse Line and/or Crisis Line as requested or required for position
- 3 years experience post degree in a clinical, psychiatric and/or substance abuse health care setting. Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria
28
Utilization Management Nurse Associate Resume Examples & Samples
- An active and good standing LPN license for Illinois is required
- 1-2 plus years of clinical experience is required
- 2 years of managed care experience is preferred
29
Utilization Management Nurse Resume Examples & Samples
- Nursing Baccalaureate degree (BSN) from an accredited school of nursing
- Current Washington State Nursing license
- Three or more years of RN experience in a clinical setting
- ACM or CCM certification
- One or more years of case management experience
30
Utilization Management Nurse Associate Resume Examples & Samples
- An active and good standing LPN license is required for the state of Utah
- 3-5 years clinical experience in a hospital setting is required
- 1-3 years of Managed Care experience is preferred
- Excellent computer skills and ability to multi task and navigate multiple computer systems including Outlook, Word and Excel are required
- Excellent verbal/written communication skills are required
- Experience with Medicare is preferred
31
Utilization Management Nurse Consultant Resume Examples & Samples
- Minimum of 3-5 years of clinical experience required (preferably in an acute hospital inpatient setting)
- Minimum of 1-3 years of Medical/Surgical (Med/Surge) experience required
- Active and unrestricted Registered Nurse (RN) License required
- 1-3 years of concurrent review/discharge planning experience preferred
- 1-3 years of Home Health Care Ambulatory Nursing experience preferred
32
Utilization Management Nurse Consultant Resume Examples & Samples
- An active and good standing RN license is required
- Excellent computer and typing skills are required
- Excellent time management Skills are required
- 2 years of clinical experience required
- Utilization Management experience preferred
33
Utilization Management Nurse Resume Examples & Samples
- 2+ years of Utilization Review / Case Management experience; 1+ year of Clinical experience in the Healthcare field
- FL Registered Nurse (RN) license and/or Licensed Practical Nurse (LPN)
- Knowledge of InterQual Criteria, Florida Medicaid Program, and CMS Guidelines
- Previous experience in an Inpatient and/or Outpatient setting
- 1+ year of experience in Discharge Planning in an Acute Care setting
34
Utilization Management Nurse Resume Examples & Samples
- Perform utilization management, utilization review, or concurrent review (on-site of via telephone)
- Determine medical appropriateness inpatient and outpatient services following evaluation of medial guidelines and benefit determination
- Assess and interpret customer needs and requirements
- Provide explanations and information to others on Difficult issues
- Coach, provider feedback and guide others supplying health education as needed
- Participate in Clinical Services Coordinator mentoring and on-going education
- Unrestricted RN license required in state of residence
- 4 or more years of Managed care and / or Clinical experience
- Experience with the Elderly and / or Intellectually Disable (ID) or Developmentally Disable (DD) population
- 2+ years of experience with documenting processes and practices while effectively prioritizing multiple tasks, priorities, projects and deadlines
- Proven ability to build collaborative relationships, work with colleagues and external audiences and partner in areas of system change, housing development / operations and / or the delivery of supportive services
- Ability to take initiative to implement projects and pursue goals with moderate supervision
- Intermediate level of proficiency with PC based software programs and automated database management systems required (Excel, Access, PowerPoint)
- Experience and knowledge with Medicaid / TennCare and Long-Term Services and Supports providers
- Ability to navigate a Windows environment including Microsoft office
- Excellent written and verbal communication and presentation skills
- Ability to balance multiple high priority
35
Utilization Management Nurse Consultant Resume Examples & Samples
- 3-5 years of Clinical experience (Required)
- Active Unrestricted RN license (Required)
- Managed Care experience (Preferred)
36
Utilization Management Nurse Reviewer Resume Examples & Samples
- Evaluates clinical information using established national decision support criteria, Medical Mutual policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Advisor. Manages initial, concurrent and retrospective review of cases, including appeals. Initiates and maintains positive relationships with internal and external customers. Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner. Identifies and refers members with potential health care needs to case and health management services. Coordinates with other care management departments to ensure the timely provision of covered health care services
- Registered Nurse with 3 years recent nursing experience with State of Ohio license
- 3 years current medical/surgical experience
- Knowledge with medical terminology/coding and managed care processes
- Personal Computer skills using Windows-based programs and applications, including Basic MS Office Skills
37
Utilization Management Nurse Reviewer Resume Examples & Samples
- Evaluates clinical information using established national decision support criteria, Company policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Reviewer
- Manages initial, concurrent , and retrospective review of cases, including appeals
- Initiates and maintains positive relationships with internal and external customers
- Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner
- Identifies and refers members with potential health care needs to case and health management services. Coordinates with other care management departments to ensure the timely provision of covered health care services
- Registered Nurse with 3 years recent nursing experience
- 3 years current medical/surgical nursing experience
- Licensed State of Ohio Registered Nurse
- Knowledge with medical terminology/coding and managed care processes. Personal Computer skills using Windows-based programs and applications, including Basic MS Office Skills
38
Utilization Management Nurse Resume Examples & Samples
- No prior UM experience necessary. We will train. Hospital experience helpful, but new grads will be considered
- Ability to apply UM criteria, and conduct telephone inpatient review of hospital/SNF patients. Must be able to review medical records at times
- Ability to coordinate discharge plans
- Excellent clinical knowledge required
- Ability to be nimble and learn to think out of the box important
- Ability to be professional in all dealings within and outside the company
39
Lpn-utilization Management Nurse Associate Resume Examples & Samples
- 3-5 years clinical experience in a hospital setting is required; 1-3 years of managed care experience
- Excellent computer skills and ability to multi task and navigate multiple computer systems including Outlook, Word and
- Excel are required
40
Utilization Management Nurse Resume Examples & Samples
- Conduct telephonic reviews for inpatient facilities for both concurrent and retrospective reviews for appropriateness of treatment setting reviews to ensure compliance with applicable criteria
- Process Prior Authorization requests for medical necessity of Outpatient services including Rehab, Home Health and DME
- Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilize evidence-based criteria that incorporates current and validated clinical research findings. Practice within the scope of their license
- Provide care coordination for members who are transitioning from one level of care to another
- Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge, transfer and redirection
- Identify barriers to efficient utilization and facilitate resolution
- Collaborate with other departments to resolve claims, quality of care, member or provider issues
- Identify problems or needed changes, recommends resolution, and participates in quality improvement efforts
- Maintain and enhance relationships between the business and the provider community
- Provide consistent and accurate documentation
- Plan, organize and prioritize assignments to comply with performance standards, corporate goals, and established timelines
- Consult with physician advisors to ensure clinically appropriate determinations
- Work within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means
- 2 – 5 years’ related experience; or an advanced degree without experience; or equivalent directly related work experience
- 1-3 years’ experience in Concurrent Review, preferred
- Previous experience in Medicare Advantage managed care and Medicaid programs is a plus
- Experience with ESRD and/or dialysis is a plus
- Familiarity with CPT and ICD codes a plus
- Familiarity with Medicare Guidelines and MCG a plus
- Effective time management
- Capable of priority setting
- Collaboration and negotiation skills
- Excellent analytical skills
- Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications
- Must be organized and detail oriented with a strong bias for follow-up and problem resolution
- Ability to learn quickly and retain complex information
41
Utilization Management Nurse Resume Examples & Samples
- Screening of PAL procedures. Conference calling will be performed from the Central Office
- Maintenance of documentation on concurrent review through the automated AMISYS Medical Management System
- Retrospective chart review of questionable hospitalizations in outlying hospitals when indicated. Chart audit of inpatient charges
- Work closely with physician advisors and Medical Directors Council to update and maintain policy according to industry standard
- Maintain direct review responsibilities for a designated geographic area of review
- Any additional duties as assigned
42
Utilization Management Nurse Resume Examples & Samples
- Provide prior authorization utilization management to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services
- Knowledge of health insurance industry trends, technology and contractual arrangements
- General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems
- Strong verbal, written and interpersonal communication and customer service skills
- Ability to interpret policies and procedures and communicate complex topics effectively
- Strong organizational and time management skills with the ability to manage workload independently
- Ability to think critically and make decisions within individual role and responsibility
- Must have current unrestricted Registered Nurse (RN) license, in a state or territory of the United States, that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline and at least 3 years (or full time equivalent) of direct clinical care
- Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license
- Consults with physician advisors to ensure clinically appropriate determinations
- May facilitate transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence’s Case Management to achieve optimal recovery for the member
- Serves as a resource to internal and external customers
- Collaborates with other departments to resolve claims, quality of care, member or provider issues
- Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts
- Responds in writing, by phone, or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues
- Provides consistent and accurate documentation
- Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines
43
Utilization Management Nurse Clinician Resume Examples & Samples
- Managed Care experience preferred. 3-5 years of clinical experience; Required
- Registered Nurse with Behavioral Health experience; Required
- Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding; Required
- Effective communication skills, both verbal and written; Required
- Ability to multitask, prioritize and effectively adapt to a fast paced changing environment; Required
44
Utilization Management Nurse Rn-telecommute Resume Examples & Samples
- Coach, provide feedback and guide others
- Critical analysis of case manager UM submission with review of supporting tools
- Communication and collaboration with Medical Director
- Case preparation and presentation for Medical Director review
- Documentation in HER of supportive rationale for UM decision
- Timely and accurate documentation in database of UM decision
- Ability to create, edit, save and send documents utilizing Microsoft Word
- State Medicaid Managed Care Experience
- Pre-authorization experience
45
Utilization Management Nurse Case Management Resume Examples & Samples
- Medical record investigative review knowledge
- Computer knowledge including basic computer skills; Windows and Outlook
- Knowledge of specific Florida Hospital computer-based programs as well as Microsoft word, Excel and Outlook (Preferred)
- Nursing education
- Acute clinical experience of at least five (5) years
- Acute clinical case management, discharge planning and/or utilization management experience in a healthcare clinical setting, i.e. hospital, managed care, home health, and/or Center for Medicare and Medicaid Services Programs, etc. (Preferred)
- BSN (Preferred)
- Certification specialty preferred in Utilization Management, Managed Care or other applicable professional certification (Preferred)
46
Utilization Management Nurse Consultant Resume Examples & Samples
- Proficient in navigating between multiple systems with dual monitors; Required
- Accurately touch type on a keyboard at efficient speed; Required
- The ability to exercise independent and sound judgment, has strong decision-making skills and well-developed interpersonal skills; Required
- Ability to manage multiple priorities, effective organizational and time management skills along with strong teamwork skills; Required
- Managed Care experience and prior experience within a telephonic customer service center type of environment; Preferred
- Candidate must possess strong computer skills
- ATV and ASD for internals candidates; Required
47
Utilization Management Nurse Consultant Resume Examples & Samples
- An RN license is required
- Strong communication and technology skills are required
- Discharge planning experience is preferred
48
Utilization Management Nurse Associate Resume Examples & Samples
- 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years; Required
- Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel Excellent verbal/written communication skills; Required
- Able to work independently in a virtual environment - and adjust to change; Required
- Precertification or prior authorization experience ; Strong Preference
49
Utilization Management Nurse Resume Examples & Samples
- Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management interventions in the current electronic system
- Monitors and updates accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care
- Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate
- Updates discharge list for last covered day. Calls discharge date to payer or submit discharge review
- All new admission reviews are to be completed within 1 business day
- Confirmation of pre-certification or authorization for admission
- Interqual Criteria is to be utilized with each new admission as well as with every denial
- Inform the case manager of any issues or plans noted in the documentation
- Self-Pay cases should be referred to Family Health Coverage Program (FHCP) and/or Social Work to determine if coverage is pending or if application for coverage has been made
- Adheres to established departmental policies, procedures, and objectives
- Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars
- Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops
- Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position
- Demonstrates a courteous and professional manner through interactions with internal and external customers
- Integrates scientific principles and research based knowledge in decision making
- Exemplifies a professional image in appearance, manner and presentation
- Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development
- Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes
- Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
- Performs other related duties as assigned
50
Utilization Management Nurse Review Specialist Resume Examples & Samples
- The UM nurse is responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice
- Assist in the control of utilization of resources, pre-occurrence monitoring, concurrent monitoring, intervention and retrospective review
- Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives
- Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice
- Facilitate quality health care intervention recommendations
- Review and assess over/under utilization issues
- Respond to inquiries by provider/site employees relating to standards of care and best practices
- Develop and maintain pre-established review parameters under the direction of the Corizon Medical Director
- Identify and document comparisons with community standards, regionally based as indicated
- Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting
- Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time
- Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management
- Assist with the data collection and reporting related to the UM outpatient/inpatient process
- Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license
- Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements
- Assist in completion of special projects on an as needed basis
51
Utilization Management Nurse Consultant Resume Examples & Samples
- RN with current unrestricted New York state licensure; Required
- Proficiency with computer skills which includes navigating multiple systems and keyboarding
- Effective communication skills, both verbal and written. Ability to multitask and prioritize
52
Utilization Management Nurse Consultant Resume Examples & Samples
- Ability to work nights and weekends per business needs
- Managed care experience preferred
- Benefits management experience preferred
- CCM (Certified Case Manager) preferred
53
Rn-utilization Management Nurse Consultant Resume Examples & Samples
- Managed Care experience preferred
- Inpatient (Hospital) experience is required
- ICU, ER or Med/Surg are highly preferred!
- Strong computer and typing skills are needed!
- Must know Word and Outlook!
54
Utilization Management Nurse Rn-ridgeland Resume Examples & Samples
- Will work Onsite at: 795 Woodlands Parkway, Suite 301 Ridgeland MS 39157
- Perform utilization management, utilization review, or concurrent review (on-site or telephonic Care coordination)
- Monitor, Track, and trend and report Utilization Inpatient and Outpatient Service Patterns
- Act as a resource for others with less experience
- The position is required to be onsite and works closely with the Health Services Director to ensure contractual compliance (Contributes RFPs and proposals and review if internal policies and procedures)
- Will be responsible for program evaluation for Utilization Management Program evaluation and Coordinating reports for Quality Committees
- Responsible for assisting providers with UM processes
- Reviewing and responding to appeals and general inquiries and state inquiries
- 3 or more years of Managed Care and / or Clinical experience required
- Undergraduate degree
