Utilization Review Nurse Resume Samples

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VB
V Bartell
Vergie
Bartell
7279 Labadie Corners
New York
NY
+1 (555) 309 3875
7279 Labadie Corners
New York
NY
Phone
p +1 (555) 309 3875
Experience Experience
Chicago, IL
Utilization Review Nurse
Chicago, IL
Monahan Inc
Chicago, IL
Utilization Review Nurse
  • Develop and maintain effective working relationships with providers and as SME/Consultant for nurse care managers and other departments within HPHC
  • The Nurse assists in the refinement/improvement of the utilization management program through participating in continuous process improvement endeavors
  • Refers claims back to medical case management unit when work status changes or medical condition warrants per criteria for case management referral policy
  • Applies worker’s compensation regulations, state laws and guidelines to case management activity in assigned territories
  • Develop and maintain effective professional relationships with injured workers, medical providers, employers and claims adjusters
  • The Nurse performs special projects or other assignments as requested by the Supervisor, Manager or Director
  • Adheres to accreditation, contractual and regulatory timeframes in performing all utilization management review processes
Chicago, IL
Telephonic Utilization Review Nurse Onsite
Chicago, IL
Hessel, Rogahn and Bashirian
Chicago, IL
Telephonic Utilization Review Nurse Onsite
  • Work with providers and members to identify contracted providers for provision of services
  • Responsible for providing support to teammates as directed by Management
  • Attends all other team and departmental meetings upon request of the Supervisor, Manager, or Director of Care Management
  • Adheres to quality assurance standards and all utilization management policies and procedures
  • Advises supervisor of any concerns or complaints expressed by providers or members
  • Maintains and sends hospital logs as assigned
  • Demonstrates sensitivity to culturally diverse situations, members, and clients
present
New York, NY
Associate Utilization Review Nurse, LPN
New York, NY
Murphy Inc
present
New York, NY
Associate Utilization Review Nurse, LPN
present
  • Acts as resource and decision making party to ensure that a clinically sound decision is administered. Works collaboratively with other departments to implement policies and procedures that directly impact the specialties benefit
  • Educates external providers about HPHC’s utilization management guidelines for specialty services
  • Receives incoming requests for specialty services; coordinates receipt of patient medical records and related clinical information
  • Complies with all regulatory and accreditation agency standards
  • Actively participates in team meetings and case conferences to identify issues, research problems and develop/implement solutions; work effectively with other internal departments for problem identification and resolution
  • Participate in personal and peer based professional growth and development opportunities to ensure clinical knowledge stays current
  • Reviews and processes authorization review requests for determinations within regulatory turnaround time
Education Education
Bachelor’s Degree in Nursing
Bachelor’s Degree in Nursing
Florida International University
Bachelor’s Degree in Nursing
Skills Skills
  • Strong medical skills and knowledge
  • Strong clinical skills and knowledge
  • Ensuring clinical information is available, and if not, following up to ensure information is available
  • Comfortable with technology and willing and able to learn new software tools
  • Strong attention to detail
  • Highly organized and able to prioritize and follow through on multiple projects in a timely manner
  • Great computer skills including solid understanding of how to use email programs, Word, Excel, etc
  • Able to multitask and manage tasks to completion on a timely basis and in an organized fashion
  • Able to act as a role model, demonstrating appropriate problem-solving skills and stress-management skills
  • Able to effectively communicate both in writing and verbally
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14 Utilization Review Nurse resume templates

1

Utilization Review Nurse Resume Examples & Samples

  • Current unrestricted license as a Registered Nurse in the State of New York
  • Bachelor’s Degree in Nursing with at least five years’ experience
  • At least 3 years experience in adult, acute care setting (Med-Surg, ER, Critical Care)
  • Experience in Home Health, Community Health/Outreach or acute care UR/Discharge Planning
  • Self-motivated and self-directed and possess the ability to solve problems independently
  • Able to work with other departments/functional areas and be seen as a team player
  • Highly organized and able to prioritize and follow through on multiple projects in a timely manner
  • Wiling to learn more advanced skills
  • Experience in Managed Care organization
  • Bilingual
2

Utilization Review Nurse Resume Examples & Samples

  • Associate’s or Bachelor’s Degree (or higher) in Nursing and/or a Health related field or accredited Nursing School Diploma
  • Proficiency in the use of personal computers and supporting software in a Windows based environment, including MS Office products (Word, Excel, PowerPoint) and Lotus Notes
  • Working knowledge of principles of utilization management
3

Utilization Review Nurse Resume Examples & Samples

  • Active Registered Nurse license in New York, Texas, or California
  • Willingness to obtain additional state licenses as needed
  • 2 years of utilization review experience at a managed care plan or provider organization
  • 5 years of healthcare experience (including at least 2 years clinical practice in an acute care setting)
  • Comfortable with technology
  • Willing and able to learn new software tools
  • Clear written and spoken communication skills
  • Registered Nurse license in multiple states
4

Utilization Review Nurse Resume Examples & Samples

  • Active RN license strongly preferred
  • Active LPN license
  • Utilization Review Experience
5

Utilization Review Nurse Resume Examples & Samples

  • 1+ year of Utilization Review experience at a Managed Care Plan or Provider organization
  • Active FL Registered Nurse (RN) license in FL
  • Appeals / Denials experience
6

Utilization Review Nurse Resume Examples & Samples

  • RN with two years clinical nursing experience
  • Knowledge of ICD9 coding and CPT procedures
  • Must demonstrate the ability to understand state laws and utilization guidelines as they apply to case management activity
  • Active and unencumbered professional license
  • Utilization review experience desirable
  • Strong organizational and time management skills
  • Develop and maintain effective professional relationships with injured workers, medical providers, employers and claims adjusters
  • Anticipates the needs of the claimant and adjusters to produce result-oriented service
  • Demonstrates basic knowledge of UR process to review all medical treatment requests utilizing state guidelines and proprietary criteria to determine appropriateness and medical necessity
  • Directs certified care into network providers as applicable
  • Follows all standards, procedures and protocols for URAC accreditation
  • Applies worker’s compensation regulations, state laws and guidelines to case management activity in assigned territories
  • Utilize Physician Advise services to make medical necessity decisions as indicated
  • Complete requests for service within five (5) business days of receipt or per jurisdictional guidelines if more stringent
  • Identifies files that may meet established criteria for referral to telephonic case management
  • Maintains updated knowledge of occupational illness management; knows where to find additional resource information as needed
  • Maintains updated knowledge of ODG, ACOEM, and jurisdictional guidelines
  • Maintains an overall QA average of 94% on reviewed files
  • CCM or CPHM certification within 2 years of hire suggested
  • Maintains acceptable attendance and tardiness
7

RN Telephonic Utilization Review Nurse Resume Examples & Samples

  • Experience in post acute, SNF and/or home health setting
  • Understanding of transition of Medicare
  • Previous experience in utilization management
8

Utilization Review Nurse Resume Examples & Samples

  • 2+ years of experience in Medicaid and Medicare Managed Care performing pre-authorization, concurrent review or case management
  • Knowledge of insurance terminology
  • Ability to perform ICD and CPT coding
  • Certification in Utilization Review
9

Licensed Utilization Review Nurse Resume Examples & Samples

  • Conducts pre-certification, inpatient (if not associated with CM or DM triage) retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
  • Develops relationships with physicians, healthcare service providers, and internal and external customers to help improve health outcomes for members
  • Educates the member about plan benefits and contracted physicians, facilities and healthcare providers
  • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards
  • Current active unrestricted license or certification to practice as a health professional within the scope of licensure in the State of VA required
10

Utilization Review Nurse PRN Resume Examples & Samples

  • Provides insurance company with detailed clinical information to when required to complete the authorization and pre-certification process
  • Communicates and attempts to resolve level of service discrepancies between CCF and insurance companies
  • Completes responses on behalf of physician for denials
  • Reviews medical records and communicates with physician to obtain authorization. Coordinates peer to peer reviews with CCF physician and insurance company Medical Director (reviews are completed for CCF physician at Main Campus and the Community Hospitals)
  • Adheres to all JCAHO and Medicare compliance regulations
  • Two years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center
  • Excellent verbal and written communications skills required to communicate will all levels in a health care environment
11

Utilization Review Nurse Resume Examples & Samples

  • Assesses the medical necessity, quality of care, level of care and appropriateness of health care services for plan members
  • Certifies cases that meet clinical review criteria, guidelines and/or screens
  • Current CCM credential is a plus
  • Must have strong oral and written communications skills
  • Must be proficient in navigating through multiple computer applications
12

Ubc-utilization Review Nurse Resume Examples & Samples

  • Provides
  • Acts
  • Licensure- Practical Nurse
  • General PC knowledge including Microsoft
13

Utilization Review Nurse Resume Examples & Samples

  • 5 years of healthcare experience, including at least 2 years of clinical practice in an acute care setting
  • Ability to multitask and manage tasks to completion on a timely basis and in an organized fashion
  • Comfortable with technology and willing and able to learn new software tools
  • Clear written and spoken communication skills, including a poised phone presence
14

Utilization Review Nurse Resume Examples & Samples

  • 3+ years of experience in Utilization Review and Discharge Planning
  • Working knowledge of Interqual Criteria, Milliman Care Guidelines, CMS and Joint Commission requirements
  • Solid analytical and problem solving skills
  • Experience in a Clinical setting
15

Utilization Review Nurse Resume Examples & Samples

  • 2-3 years of chart review or medical record review experience
  • Ability to work independently and meet deadlines
  • Good understanding of medical terminology
  • Ability to read, discuss and understand patient medical information
  • Ability to interact effectively with a variety of people and situations at all levels of the organization
  • Care Management or Utilization Review experience
  • Case Management or Utilization Review certification
16

Licensed Utilization Review Nurse Resume Examples & Samples

  • The management and coordination of "Fast Track" appeals performed by CMS' Quality Improvement Organizations (QIO)
  • Reviewing previously denied/discontinuation of concurrent service by Health Plan or Delegate UM, extracting data, researching Medicare guidelines to support denied services and to complete the detailed explanation notices of already denied services for submission to the member, provider and QIO
  • Facilitates accreditation by knowing, understanding, and accurately applying accrediting and regulatory requirements and standards. Performs other related duties as required
17

Utilization Review Nurse Supervisor Resume Examples & Samples

  • Two years' experience as a registered nurse, including one year in the treatment of chronic and short- term medical and surgical inpatient problems, and one year's experience in the first-level supervision of nurses, including registered nurses
  • A bachelor's degree**** in Nursing from an accredited nursing program
  • Additional experience of first-level supervision of nurses, including registered nurses
18

Utilization Review Nurse LPN Resume Examples & Samples

  • Obtain authorizations for post discharge, prebill accounts
  • Perform re-certification for additional days on post discharge, prebill accounts
  • ERequest/ Passport queues as determined during program implementation
  • Communication- communicates professionally, clearly and concisely
  • Interpersonal skills –ability to establish and maintain collaborative and effective working relationships
  • Policies & Procedures -demonstrates knowledge and understanding of organizational policies, procedures and systems
  • Basic skills– demonstrates ability to organize, perform and track multiple tasks accurately in short timeframes and have ability to work quickly and accurately in a fast-paced environment while managing multiple demands
  • Clinical skills –ability to read/ interpret medical record documentation and present the clinical data obtained in an organized, concise dialogue to the payor in order to obtain auth and/or resolve other issues
  • Utilization Review, appeals, denials, managed care contracting, experienced preferred
19

Licensed Utilization Review Nurse Resume Examples & Samples

  • Requires an LPN, LVN, or RN; 2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background
  • Appeals experience required
  • Strong computer skills preferred
  • Current active unrestricted license or certification to practice as a health professional within the scope of licensure in CT required
20

Utilization Review Nurse Resume Examples & Samples

  • Education: Registered Nurse, Associate degree or higher
  • 3-5 years’ experience in Medicare Advantage Health Plans or related experience in a healthcare setting handling complex inquiries and requests for service
  • Working knowledge of Medicare Advantage, Original Medicare and or Medicaid appeal regulations. Understanding of Local Coverage Determinations, National Coverage Determinations, Medicare claim process and plan rules along with working with of ICD9, ICD10
  • Superb written and oral communication skills with particular emphasis on verbally presenting case summary and decisions
  • Must have the ability to work objectively and provide fact based answers with clear and concise documentation
  • Ability to work independently and under pressure
  • Attention to detail and critical thinking skills
21

Utilization Review Nurse Resume Examples & Samples

  • Associate Degree
  • 3 or more years of related clinical nursing or case management experience
  • Must be a registered nurse with a minimum of 3 years' clinical experience in medical, surgical, orthopedic, neuro-surgery or psychiatric nursing
  • Must possess an unrestricted active license in State of IL
  • Must be a registered nurse with a minimum of 5 years' clinical experi
  • Computer literacy, Excel, Word, Outlook Exchange
  • CPUR preferred
22

RN Utilization Review Nurse Bedford, Texas Resume Examples & Samples

  • Responsible for the effective and sufficient support of all clinical appeal reviews according to policies and procedures
  • Refers cases to the Medical Director as appropriate
  • Evaluates and refers cases to the quality of care and chronic case improvement programs as needed
  • Maintains strong working relationship with internal and external customers and professionally communicates information as needed or required
  • Documents information into the appeal system
  • Provides leadership to other team members
  • Serves as a preceptor for new employees
  • Compliant with turnaround times and maintains unit goals
  • Follows Texas and Illinois Medicaid and CMS Medicare benefit structure for coverage of services
  • Willingness to learn new information
  • Must have current licensure as a Registered Nurse (RN) with no restrictions
  • At least five years clinical experience with at least three years in utilization review/discharge planning
  • Knowledge of ICD-10 and CPT coding guideline and evidence-based criteria to establish medical necessity
  • Demonstrates strong verbal and written communication skills, negotiations and interpersonal skills
  • Demonstrates leadership (organizational) skills in team orientation, problem-solving, decision-making, conflict resolution, and the ability to work independently
  • Demonstrated knowledge of regulations for Medicare, Medicaid and insurance processing and coding, strongly preferred
  • Demonstrated organizational skills, time management, detail orientation, flexibility and ability to work with minimal supervision
  • Demonstrates an exceptional interpersonal skill
  • Strong Knowledge of Microsoft Office including Outlook, Word, Excel, and PowerPoint
23

Pre-certification / Utilization Review Nurse Resume Examples & Samples

  • Adherence to regulatory and departmental timeframes for review of requests received
  • Successfully collaborates with member and family to assure comprehension of available resources
  • Registered Nurse license along with 1+ years experience in a Managed Care environment
  • Working knowledge of medical coding (CPT/ICD-9) and medical necessity criteria (e.g., InterQual, Highmark, Trail Blazer)
  • Excellent interpersonal and communications skills with nursing staff, physicians, nurse practitioners and other health workers involved in the care of a member
  • Excellent typing skills
24

Utilization Review Nurse Resume Examples & Samples

  • Requires a valid RN licensure without in the state of residency without any restrictions or stipulations
  • Should have a minimum of 2 years of clinical experience
  • Strong computer skills; good understanding of how the computer works and comfort navigating through different system applications. Should have the ability to troubleshoot computer issues
  • Strong typing skills; knowledgeable of Microsoft Office- Word, PowerPoint, Excel; knows how to use Outlook for emails and calendar. If they have only done computerized charting or FB this is not enough. Must be able to type using two hands
  • Works well independently. Aware of limitations and knows when to ask for assistance
  • Ability to change direction easily and ability to learn and apply quickly
  • Must be able to work in a fast paced environment with changing priorities
  • Ability to deal with complex issues with multiple steps/resources involved in resolution
  • Should not be easily frustrated
  • Should be able to work well under pressure, meet timelines and production goals
  • Must have reliable cable, internet and power if they work from home. Time lost with any issues that do not originate within Cigna are the responsibility of the employee to make up
  • Tenacious and Persistent
  • May be required to sit for long periods of time
  • If WAH, must have office space where Cigna equipment can be secured and a space that is conducive to a healthy, productive work environment
25

Licensed Utilization Review Nurse Resume Examples & Samples

  • Current unrestricted LPN or LVN license in Ohio
  • 1 year of related experience in a managed care setting, utilization review, or equivalent background or experience
  • At least 2 years of prior Utilization Review or Appeals experience is preferred
  • Strong oral and written communication skills, organizational, problem-solving, and computer skills required
26

Utilization Review Nurse Resume Examples & Samples

  • Reviews medical records for appropriate application of medical necessity criteria to determine the appropriateness of admission and/or continued stay and readiness for discharge using InterQual criteria and clinical expertise
  • 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
  • Performs concurrent clinical review for patients to ensure that extended stays are medically justified and are so documented in patient's medical. Communicates with attending physician regarding patients clinical condition, signs and symptoms as needed to ensure the patient’s admission status is supported by the physician’s documentation consistent with industry accepted guidelines and payer rules/regulations
  • 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
  • Enters clinical reviews into the UM Module within Cerner and works with the Utilization Review Coordinators to ensure necessary concurrent clinical information is transmitted to third-party payers and required by the payer and/or any payment contract with facility
  • 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
  • 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
  • Performs concurrent review of acute and sub-acute services, as well as precertification review for all services following the plans authorization guidelines
  • Predicts and plans for patient’s needs from admission through acute and sub-acute care and post-discharge, in collaboration with the patient’s third-party payer and providers
  • 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
  • Participates in a regular rotation of weekend and after-hours coverage in order to meet Department needs as determined by the Director of Case Management
  • Licensed as a Registered Nurse
  • Certification in clinical case management or utilization review strongly desired
  • Bachelor’s degree in Nursing (BSN) or Associate’s degree in Nursing (ASN) with Bachelor’s degree in a closely related field required
  • Minimum of 3 years nursing experience prior to care coordination required
  • Knowledge of Medicare and Medicaid payment rules, policies and regulations
  • Ability to effectively use MS Word and Outlook 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 establish and maintain effective and cooperative working relationships with Hospital staff and others contacted in the course of this position
  • Ability to work as a part of a team
  • Ability to accurately complete tasks within established times
  • Demonstrated ability to effectively prioritize multiple tasks and deadlines and work independently
  • Ability to maintain confidentiality in all tasks performed
  • Demonstrated ability to effectively present information and respond to questions from small groups or on a one-on-one basis
  • Demonstrated ability to deal with problems involving several concrete variables in standardized situations
  • At least 5 years nursing experience prior to care coordination preferred
27

Care Manager Utilization Review Nurse Resume Examples & Samples

  • Graduate of accredited school with Bachelor’s or AA Degree in Nursing (BSN) orrelated degree
  • Current Washington State: RN/PT/OT
  • Current Washington State drivers license
  • Proof of auto insurance
  • Requires knowledge of Medicare skilled nursing criteria
  • Minimum 3 years experience in: Rehab medicine, skilled nursing facility with sub-acute care, discharge planning, case/care management required
  • Certified Case Manager Preferred
  • Some familiarity with Medicare acute care criteria preferred
  • Health plan experience preferred
28

Utilization Review Nurse Resume Examples & Samples

  • Review all inpatient admissions and initiate discharge planning in a timely manner
  • Utilize clinical skills, chart review, physician communication, and Interqual standards for approval of inpatient stay
  • Conduct ongoing review for members in inpatient stay and utilize peer review, as necessary
  • Communicate with UR Coordinator and Medical Director(s) for determination on reviews that do not meet criteria
  • Provide notification to facility of determination
  • Facilitate member’s transfers within contract facilities for ongoing inpatient stays
  • Complete documentation in electronic medical record and claims systems
  • Members are identified who have Third Party Liability coverage
  • Upon discharge, member transitions to safe, appropriate environment with effective continuity of care
  • Interdisciplinary team is engaged with the member to create discharge plan
  • Upon discharge, needed services are coordinated to ensure quality of care
  • Confirmation of appropriate level of care
  • Claims are paid within the identified time frame per the AHCCCS contract
  • Interdepartmental communication to request additional information to complete claim review
  • Medical Records and Coding
  • Interqual criteria
  • ICD-9/ICD-10 (when applicable)
  • CPT Codes and HCPCS codes
29

Pre-certification / Utilization Review Nurse Resume Examples & Samples

  • HSD or GED required; BSN preferred
  • Active RN license required
  • 1+years’ experience in a Managed Care environment
  • Intermediate knowledge of Microsoft Office including SharePoint, Outlook, PowerPoint, Excel and Word
30

Utilization Review Nurse Resume Examples & Samples

  • Conducts pre-authorization referral reviews, following workflow as written, document criteria to make determination or recommendation and process the referral in a timely manner
  • Manages assigned queues on a daily basis working oldest referrals first to assure 98% compliance with ICE timeframes
  • Follows job work aide in sequence of performing job, including checking eligibility on health plan websites. Demonstrates 100% accuracy of identification of DHMG-IE/DHPN-IE member before referral review is initiated
  • Determines correct type of referral and utilizes correct criteria in performing review and documents appropriate sections with 95% accuracy
  • Researches correct information and/or uses pend letter appropriately when facts are needed to reach determination
  • Preps case thoroughly, concisely and clearly for physician review. Researches EMR, criteria, medical policy and past history of member to detail case cleanly for MD in 95% of the cases
  • Watches for follow up and processes denials as indicated, demonstrating wording at 6th and or 8th grade level, clear sentence structure and correct identification of reasons for denial
  • Communicates findings to physician and member in accordance with all regulatory and of DHMG-IE/DHPN-IE guidelines and documents same in 95% of cases
  • Supports co-workers to covers needed staffing, training or special projects as assigned
  • The Nurse performs audits of medical records as requested or appropriate
  • Recommends and coordinates interventions to facilitate high quality, cost-effective care, monitoring treatment, progress and outcomes of patients
  • The Nurse performs Inter-Rater Reliability audits as directed by the UM Supervisor or UM Manager
  • The Nurse scores over 95% on personal Inter-Rater audits as reviewed by peers
  • The Nurse assists in the refinement/improvement of the utilization management program through participating in continuous process improvement endeavors
  • The Nurse uses professional and collaborative behavior while interacting with all customers
  • The Nurse demonstrates the ability to work within their scope of practice as defined by the Department in all stages of work
  • The Nurse responds promptly and with courtesy to inquiry from claims, other hospitals, other departments seeking assistance, member services, management, physicians and others by either resolving the situation or referring it appropriately. Documentation is completed for all issues to create a record
  • The Nurse requests assistance when needed to ensure that the appropriate actions are taken in each situation
  • The Nurse performs special projects or other assignments as requested by the Supervisor, Manager or Director
  • Dignity - Respecting the inherent value and worth of each person. Justice - Advocating for social change and acting in ways that promote respect for all persons and demonstrate compassion for our sisters and brothers who are powerless. Stewardship - Cultivating the resources entrusted to us to promote healing and wholeness. Collaboration - Working together with people who support common values and vision to achieve shared goals. Excellence - Exceeding expectations through teamwork and innovation
  • Consistently and positively communicates and collaborates with colleagues, supervisor, and customers (internal and external). Communicates collaboratively in situations involving conflict so the conflict de-escalates and is resolved
  • Efficiently and independently plans time to accomplish job duties within departmental standards. Employee is punctual, meets deadlines, initiates and follows through on tasks, and needs little supervision
  • Meets or exceeds behavioral standards to work effectively with internal and external customers. Is professional and courteous in all situations. Anticipates needs of others and works to fulfill them. Listens respectfully and carefully, demonstrating flexibility in working with others
  • Demonstrates sensitivity to people of different cultures and works effectively with them
31

Licensed Utilization Review Nurse, / II Ohio Resume Examples & Samples

  • Requires an LPN or LVN; 2 years of clinical or utilization review experience; or any combination of education and experience, which would provide an equivalent background
  • Current active unrestricted license or certification to practice as a health professional within the scope of licensure in Ohio required
  • Knowledge of the medical management process preferred
  • Medicare knowledge preferred
  • WMDS experience preferred
  • Strong computer skills required
32

Senior Utilization Review Nurse Consultant Resume Examples & Samples

  • Assess member’s needs
  • Collaborate with staff, physicians, care/service coordinators, plan Medical Director, members and their families to coordinate and provide the level of care necessary to meet member’s health need
  • Ability to work remotely and be available for daily huddle calls via conference call and or WebEx sessions
  • Project Management and collaboration with leadership on deliverables
33

Case Manager Utilization Review Nurse Resume Examples & Samples

  • Minimum of three (3) years of clinical experience in nursing; Minimum of one (1) years in acute hospital case management and utilization review for Medicare, Managed Care and Commercial payers
  • Must have knowledge of Interqual
  • Must have demonstrated prior job interactivity with multiple departments, disciplines and physicians, as well as organizational levels. Must have knowledge of DRGs and GMLOS
34

Utilization Review Nurse Resume Examples & Samples

  • Demonstrates expertise in the application of InterQual and Milliman criteria
  • Reviews of clinical data for ED admits,
  • Manages all direct admits, clarifying level of care orders and performing Milliman/InterQual screening as appropriate. Acquires additional information if necessary to assist in level of care determination
  • Insures operative procedure performed is the operative procedure prior-authorized with the third party payor and communicates any variance
  • Performing clinical reviews of all inbound transfers for appropriateness
  • Monitors use of healthcare resources. Communicates with physicians to assure patient receives diagnostics/evaluations in the proper setting, i.e. inpatient vs outpatient
  • Maintains current knowledge of CMS (Medicare) rules and regulations
  • Communicates openly with third party payors and works collaboratively with them to avoid concurrent denials
  • Collaborates with the care coordinator to ensure appropriate level of care,
  • Actively participates in the multidisciplinary team meetings
  • Identifies and documents delays in service
  • Serves as an expert resource to physicians and healthcare staff in the application of InterQual criteria and the use of evidence based practices
  • Conducts initial (admission) reviews at the time of presentation, or within 24 hours, if patient presents during uncovered hours
  • Conducts concurrent review per department policy (every three days for Medicare unless the patient condition changes), and as private payor dictates
  • Conducts observation reviews daily
  • Follows department policy regarding escalation of utilization issues to the Physician Advisor or his/her designee
35

Utilization Review Nurse RN Resume Examples & Samples

  • Reduce managed care denials by providing clinical updates timely
  • Effectively manage eRequest and keep accounts worked on a daily basis
  • Provide clinical information for Medicaid accounts through eQHealth Solutions
  • Assist with denial management and appeals
  • Provide cross coverage as needed
  • 3 years nursing experience in acute care setting is required
  • 1-3 years of case management experience is required
  • Managed Care and Denial Management experience is preferred
  • Prior insurance review experience preferred
  • Must be proficient in utilization of InterQual/Milliman criteria
  • Must have knowledge of accreditation standards and compliance requirements, as well as government and non-government payor practices, regulations, standards and reimbursement
  • Must work independently and is flexible with all job duties
  • Must have outstanding telephonic and personable skills to communicate with various entities, ( ie. physicians, health plans, review nurses, clerical personnel)
36

Utilization Review Nurse Resume Examples & Samples

  • Along with physician hospitalists / PCPs / Specialists, leads and coordinates activities of interdisciplinary treatment team required to make complex clinical, benefit and network decisions
  • Apply Utilization Review Management process to ensure continuity of care throughout the health care continuum including review and authorization of services applying evidence-based guidelines and per MemorialCare Foundation policy
  • Assures review turnaround times adhere to timeliness standards set by contracting and regulatory requirements and established productivity and quality guidelines
  • Decisions and documentation demonstrates prudent utilization of resources, identifies opportunities for potential cost reduction; promote quality care and comply with regulatory guidelines needed to maintain delegated status from contracted health plans
  • Documents decisions that demonstrate independent judgment, critical thinking and application of complex managed care regulations including but not limited to benefit structures, coverage, medical necessity, network contract, financial responsibility and care management
  • Independently research and determine the information necessary to complete medical necessity review
  • Initiate and complete the denial process for all services deemed to be non-covered benefits or not medically necessary
  • Participates in Contracting and Provider Relations activities as necessaryto develop and maintain provider networks. Identify and report when provider’s gaps in contracts are identified
  • Subject to standard medical management performance measurements for specific area/team including but not limited to referral turnaround times, volume, denial language and overturn rates
  • Initiate LOA process as needed for referral completion
  • Applies criteria and guidelines used for medical necessity review appropriately
  • Demonstrate the ability to apply and/or to explain managed care principles to others; i.e. contracted, non-contracted, full risk, shared risk, in and out of network, etc
  • Request appropriate clinical notes needed for referral review determination
  • Identify appropriate clinical guidelines necessary to accurately perform medical necessity review
  • Follow all department P&Ps as applicable to job
  • Demonstrate the ability to consistently utilize the computer system and software for referral review process
  • Works with Medical Director to make authorization determination using clinical care guidelines and clinical analysis of relevant chart documentation
  • Minimum 2 years of utilization / care management experience applying evidence-based criteria (i.e.: Milliman, Interqual); Health plan medical policy / clinical coverage guidelines to make authorization determinations
  • Experience performing medical management (UM) in electronic referral application preferred
  • 2 years’ work experience in Microsoft Word, Microsoft Excel and Microsoft Outlook
37

Acute Utilization Review Nurse Resume Examples & Samples

  • At least 3-5 years prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Must have good typing skills and proficiency using MS Office Word and Outlook
  • Have the ability to provide a high speed DSL or cable modem for a home office (Satellite and Wireless Internet service is NOT allowed for this role). A minimum standard speed for optimal performance of 10x1 (10mbs download x 1mbs upload)
38

Utilization Review Nurse Resume Examples & Samples

  • As insurance company, receives detailed clinical information required to complete the authorization and pre-certification process
  • Communicates and attempts to resolve level of service discrepancies between CCF and insurance company
  • Coordinates level of service justification directly with physician and communicates directly with providers regarding outcomes
  • Communicates responses on behalf of physician for review outcomes including denials
  • Reviews medical records and communicates with physician to obtain authorization
  • Coordinates peer to peer reviews with CCF physician and insurance company Medical Director (reviews are completed for CCF physician at Main Campus and the Community Hospitals)
  • Coordinates pre-determinations for specific procedures as well as maintaining confidentiality of all patient related information
  • Adheres to all compliance regulations
  • Three or more years of experience in patient care acute facility, preferably at a tertiary care medical center. Utilization Review experience preferred
  • Excellent customer service, organizational skills along with ability to work under tight deadlines
39

Network Utilization Review Nurse 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
  • Works collaboratively with the business office/finance to ensure proper reimbursement
40

Utilization Review Nurse Auditor Resume Examples & Samples

  • Must be a graduate of an accredited nursing program; bachelor’s degree preferred
  • Minimum of three to five years of direct professional patient care required
  • Experience in utilization management preferred
  • Must hold and maintain an unencumbered accepted nursing license
  • Must have strong knowledge of medical terminology, anatomy and physiology, treatment protocols, medications and laboratory values
  • Must be able to add, subtract, multiply, and divide in all units of measure, using whole numbers and decimals; Ability to compute rates and percentages
  • Must be a qualified typist with a minimum of 30 W.P.M
  • Must be able to operate a general computer, fax, copier, scanner, and telephone
  • Must be knowledgeable of multiple software programs, including but not limited to Microsoft Word, Outlook, Excel, and the Internet
  • Must possess excellent skills in English usage, grammar, punctuation and style
  • Ability to follow instructions and respond to upper managements’ directions accurately
  • Demonstrates accuracy and thoroughness. Looks for ways to improve and promote quality and monitors own work to ensure quality is met
  • Must demonstrate exceptional communication skills by conveying necessary information accurately, listening effectively and asking questions where clarification is needed
  • Must be able to work independently, prioritize work activities and use time efficiently
  • Must be able to demonstrate and promote a positive team -oriented environment
  • Must be able to stay focused and concentrate with frequent interruptions
  • Must be able to work well under pressure and or stressful conditions
  • Must possess the ability to manage change, delays, or unexpected events appropriately
  • Demonstrates reliability and abides by the company attendance policy
  • Must maintain a professional and clean appearance at all times consistent with company standards
41

Utilization Review Nurse Resume Examples & Samples

  • Collaborates with the unit Case Manager, Social Worker, attending physician, and other healthcare team members to ensure medical appropriateness criteria, to develop an action plan to avert reductions in care or denials and to obtain all payor information that influence discharge planning activities
  • Refers all cases that are denied by the payor to the Physician Advisor according to the Case Management department policy and procedure
  • Participates in at least 2 clinical process performance improvement activities related to utilization management
  • Leads and coordinates quarterly education sessions each year for internal and external customers regarding utilization management
  • Bachelor's Degree in Nursing from an accredited college or university
  • 3-5 years of clinical experience and/or case management, utilization review, and/or discharge planning experience in an acute care setting, insurance company or other healthcare related field (home health, hospice, SNF, etc.)
  • Master's Degree in Nursing from an accredited college or university
  • Experience working at or with insurance companies in the certification of healthcare services
  • RN or LVN/LPN licensure through the Texas State Board of Nurse Examiners
42

Utilization Review Nurse, PRN Resume Examples & Samples

  • Provides all required clinical information to the payor according to the payor's timeframe standards throughout the hospitalization to obtain certification approval for all services provided
  • Maintains a collaborative working relationship with the payor's utilization review nurses and case managers and maintains contact with the payor regarding initial assessment, progress, changes in condition, discharge planning, discharge date, etc. as needed
  • Takes the lead in coordinating on-going education for Case Management staff regarding government and payor regulatory and outcomes
  • Maintains productivity and meets all Case Management performance standards according to the Case Management department policies and procedures
  • Serves as the lead educational resource for other Case Management staff, other internal departments, physicians, nursing staff and others concerning utilization management strategies essential in meeting the organization's quality, utilization, financial and customer satisfaction objectives
  • 3-5 years of clinical experience and/or case management, utilization review, and/or discharge planning experience in an acute care setting, insurance company or other healthcare related field (e.g. home health, hospice, SNF, etc.)
43

Associate Utilization Review Nurse, LPN Resume Examples & Samples

  • Reviews and/or coordinates requests for authorization of specialty services with external consultants, and Physician Advisors; Uses his/her own discretion in determining if submitted medical information needs a consultant’s review
  • Applies state mandated and operational guidelines based upon benefit eligibility and clinical appropriateness
  • Acts as resource and decision making party to ensure that a clinically sound decision is administered. Works collaboratively with other departments to implement policies and procedures that directly impact the specialties benefit
  • Educates external providers about HPHC’s utilization management guidelines for specialty services
  • Receives incoming requests for specialty services; coordinates receipt of patient medical records and related clinical information
  • Complies with all regulatory and accreditation agency standards
  • Actively participates in team meetings and case conferences to identify issues, research problems and develop/implement solutions; work effectively with other internal departments for problem identification and resolution
  • Participate in personal and peer based professional growth and development opportunities to ensure clinical knowledge stays current
  • Reviews and processes authorization review requests for determinations within regulatory turnaround time
  • Other duties and projects as assigned
44

Utilization Review Nurse Resume Examples & Samples

  • In collaboration with Medical Director and Physician Advisors, review and manage requests for authorization of specialty services and uses his/her own discretion in determining if submitted medical information needs further review
  • In collaboration with other departments, assist in developing medical policies and procedures that directly impact member utilization of benefits
  • Perform clinical reviews using HPHC criteria and guidelines to determine when services are medically necessary and appropriate; includes development and management of documentation standards to achieve maximum care management outcomes
  • Manage incoming requests for procedures and services including patient medical records and related clinical information
  • Reviews and processes authorization review requests for determinations within regulatory turnaround tim
  • Develop and maintain effective working relationships with providers and as SME/Consultant for nurse care managers and other departments within HPHC
  • Ensure team compliance with all regulatory and accreditation agency standards
  • Performs special projects as assigned and participates in account activities as needed
  • Apply motivational interviewing techniques when speaking to providers
  • Serve as lead resource within the team and may coach or mentor other staff as appropriate
45

Utilization Review Nurse Resume Examples & Samples

  • Maintains recognition and acceptance of accountability and responsibility for duties and functions within the scope of the practice of the RN; collaboration with other team members towards problem resolution; precise and appropriate verbal and written communication; and behaviors consistent with the role of the professional nurse
  • Reviews patient’s medical records to collect data pertaining to diagnoses and major procedures performed, evaluates appropriateness of admission, observation and length of stay, and completes required forms
  • Reviews patient’s medical records for particular aspects of care (as directed) and/or problems which adversely affect patient care
  • Performs concurrent reviews of admissions to determine medical necessity for admission, observation and continued stays. Refers those that do not meet criteria to the Physician Advisor and/or Department Chairman
  • Performs concurrent reviews for the appropriateness of resource consumption and refers any over or under utilization to the Physician Advisor
  • Reviews specific incidents and utilization problems with Physician Advisor such as extended hospital stays, complications with care, and patients waiting for placement
  • Conducts ongoing utilization review for compliance with approved third-party treatment plan and ensures necessary interventions. Communicates with payors regarding clinical updates and the need for continued hospitalization
  • Follows through on the assessment of the RN Case Manager for discharge planning and educational needs in the absence of that case manager; plans the patient’s care and ensures that patient family teaching is complete
  • Prefer two years’ experience as a Clinical Nurse, proficient in clinical and technical skills in nursing specialty; leadership and teaching skills in order to gain a full understanding of case management practices and procedures
46

Utilization Review Nurse Resume Examples & Samples

  • Active, unrestricted, and licensed registered nurse required.Associates degree in health related field; BSN preferred
  • Three (3) years of clinical experience in acute hospital care and/or three (3) years of utilization review experience required
  • Previous experience in managed care preferred
  • Clinical knowledge of the health or social work needs for the population served
  • Demonstrated ability to identify barriers to a successful care management path
  • Demonstrated ability to interact effectively with physicians and other members of the health care system
  • Proficient PC and Windows skills required, including MS Office
  • Excellent problem-solving abilities and time management skills
  • Excellent written, verbal and interpersonal communication skills
  • Demonstrated transferable knowledge, skill and ability to complete job duties independently and proficiently.Flexibility in work schedules and assignments
  • Proven examples of displaying the Nova values: Passionate, Caring, Respectful, Trustworthy, Collaborative and Accountable
47

Utilization Review Nurse Resume Examples & Samples

  • Interfaces with medical directors, and both internal and external stakeholders, with regard to coverage for services, contract benefits and alternate resources available
  • This position interfaces frequently with treating providers in the gathering of clinical information and may also provide education on the medical review process
  • The Utilization Management clinician makes coverage decisions based on specific criteria including Milliman
  • Frequently collaborates with Fidelis medical directors in determining coverage of requested services
  • Interacts with members to assist with accessing appropriate resources for requested services
48

Telephonic Utilization Review Nurse Onsite Resume Examples & Samples

  • Provides service delivery on assigned products in a manner consistent with established standard policies/procedures and customer result expectations. Responsibilities include, but are not limited to, the following
  • Work with providers and members to identify contracted providers for provision of services
  • Utilizes trigger list to identify cases which require case management and disease management services
  • Evaluates medical information against criteria, benefit plan, and medical policies and determines medical necessity for procedure and refers to Medical Director if criteria is not met
  • Adheres to quality assurance standards and all utilization management policies and procedures
  • Advises supervisor of any concerns or complaints expressed by providers or members
  • Attains established production standards and operational objectives including reviews/transactions completed per day, case documentation, and telephone response requirements
  • Compliant with all accreditation, state, and federal mandates
  • Maintains and sends hospital logs as assigned
  • Attends Concurrent Review meetings on a weekly basis
  • Attends all other team and departmental meetings upon request of the Supervisor, Manager, or Director of Care Management
  • Responsible for providing support to teammates as directed by Management
  • Complete Reinsurance notifications as per policy
  • Performs additional departmental duties below as appropriate
  • Participates on special projects/client demonstrations
  • Supports and assists with training and precepting as required
49

Office Based Utilization Review Nurse Resume Examples & Samples

  • Highly competitive pay
  • Personal and online Career Advisement and Development: Kelly Services offers access to our online training center to employees in order to maintain licensing and/or certification credentials. CEU credits can be obtained through our training center as well
  • Unprecedented contract staffing benefits for our employees including seven (7) different and affordable portable options! Benefits include: health, prescription, vision, dental etc
  • Numerous employee discounts at popular retailers, hotels, entertainment attractions, cellular companies, and universities
50

Utilization Review Nurse Resume Examples & Samples

  • Must have at least TWO (2) years of experience specifically working in Utilization Review as your main job duty – this experience must be clearly described on your resume for you to be considered
  • Must have very specific, identifiable experience working directly with insurance companies/payors to obtain benefit information as it relates to services provided
  • Must have very specific, identifiable experience being the sole employee responsible for communicating directly with the insurance companies/payors to maximize opportunities for authorization of services for patients
  • Must have significant knowledge and strong use of all aspects of Utilization Review including but not limited to medical terminology, Medical Records and Coding, Interqual criteria, ICD-9/ICD-10 (when applicable), CPT Codes and HCPCS codes
  • Willingness / ability to provide patient care if the UR workload is light and/or nursing team has an emergency staffing shortage
  • Current licensure in good standing in Louisiana
  • Prior nursing experience, preferably in behavioral health or addiction treatment
  • Great computer skills including solid understanding of how to use email programs, Word, Excel, etc
  • Able to effectively communicate both in writing and verbally
  • Able to positively interact and develop rapport with clients and their families, professional support staff, team members and various levels of staff from the community agencies
  • Able to act as a role model, demonstrating appropriate problem-solving skills and stress-management skills
  • Possess an understanding of the role of 12-step principles in sobriety
  • Willingness to provide excellent customer service
  • If in recovery, must have 2 years of sobriety
  • Local candidates only (no relocation)
  • Pre-certifying new admission insurance clients with insurance companies
  • Completing concurrent reviews for caseload to extend clients’ length of stay
  • Sending daily census data to clinical team and uploading for billing team
  • Communicating authorizations to clinical team to inform what level of care has been authorized for clients
  • Communicating with the insurance department if a client does not have coverage or there are limitations on client’s policy that becomes available as case is opened with insurance company
  • Working with clinical and client care team to communicate insurance case manager’s request for specific treatment, follow ups, and individualized care
  • Ensuring clinical information is available, and if not, following up to ensure information is available
51

Utilization Review Nurse Resume Examples & Samples

  • Post graduate of an accredited school of nursing and an active Registered Nurse license
  • Five (5) years' experience in acute hospital case management or equivalent
  • Utilization Management experience required
  • Proficient in word processing, spread sheets and database
  • Excellent interpersonal relationship skills with exceptional professional work ethics
  • Knowledge of Milliman Care Guidelines, InterQual Criteria, and CMS
  • Experience and knowledge of self-funded plans, ERISA, and HIPPA guidelines