Utilization Review Nurse Resume Samples

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Utilization Review Nurses review patient cases and ensure that the patient is receiving the proper treatment. Utilization Review Nurses also verify that health care costs and policies are being properly followed. Responsibilities shown on sample resumes of Utilization Review Nurses include referring cases to medical directors where appropriate, and requesting additional information to perform thorough medical necessity assessments. Utilization Review Nurses' resumes reflect a bachelor's degree in nursing, as well as registered nurse licensure and post-baccalaureate certificates in the fields of health care risk management or case management.

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1

Utilization Review Nurse

Determined appropriateness and medical necessity of hospitalization and requested treatment (s) based on plan's guidelines, policies, Milliman, and medical director review, if needed. Also, includes observation status

  • Responsible for requesting clinical information for concurrent review with strict adherence to URAQ guidelines
  • Responsible for presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging any peer-to-peer reviews, if requested by hospitalist, attending, or primary care physician
  • Assisted and/or provided facility interdisciplinary teams benefit information for in network providers/facilities, DME, home healthcare, acute, sub-acute rehab, skilled nursing facilities, and out-of-network benefits, if needed
  • Communicated frequently with assigned case managers for unplanned admissions, inpatient status, and discharge plan with orders
  • Collaborated with assigned case manager to identify members frequent hospital readmissions
  • Participated in weekly UM Grand Rounds with plan liaison, medical director, URNs and Alere oncology medical director
Candidate Info
8
years in
workforce
4
years
at this job
2

Utilization Review Nurse

Reviewed high volume case load of patient charts to determine medical necessity based on nursing knowledge and state mandated guidelines

  • Dealt one on one with numerous doctors and patients daily regarding medical treatments.
  • Answered a busy phone line to educate and explain treatments ordered
  • Spoke with insurance agents regarding ICD-9 and CPT codes
  • Collected documentation from numerous providers to add to patient medical history chart
  • Performed duties in accordance with well-established rules, procedures, regulations, principles and operations covering patient medical records, their required contents, establishment and maintenance of special registries, documentation of incidents, and diagnostic coding requirements and procedures.
  • Utilized knowledge of an extensive body of well-established medical records procedures, rules, processes, company and legal policy for multiple states and areas of responsibility; to include establishing, coding, maintaining, and disposing of patient medical records.
Candidate Info
6
years in
workforce
2
years
at this job
HS
Lpn / Clinical Skills
Clinical
3

Utilization Review Nurse

Managed comprehensive chart audits for Additional Documentation Requirements (ADR) for Fiscal intermediary review, adverse events review, and error report review for process improvement

  • Conducted OASIS Review to assess appropriateness of documentation for 485 document preparation and ICD-9 Diagnosis Coding
  • Verified compliance with Agency Policy and Procedure, State, JCAHO, and Hem 11 Guidelines
  • Managed various insurance audit reviews and subpoena audits for payer inquires
  • Conducted Medicaid/MediCal care management pre-authorization an treatment authorization requests
  • Conducted Peer Review preparation, facilitated peer review meetings, and assessed data collection of review findings
  • Trained and oriented new staff members in learning OASIS documentation procedures
  • Attended conferences to refine skills for OASIS correlation with ICD-9 coding
Candidate Info
10
years in
workforce
3
years
at this job
Adn
4

Utilization Review Nurse

Evaluated and authorized medical necessity of services

  • Prepared reports and documentation for monthly board meetings
  • Prepared and submitted monthly IPA reports for delegation audits
  • Provided supervision in operating an IPA/POD
  • Monitored and insured productivity and performance
Candidate Info
4
years in
workforce
3
years
at this job
BA
Bachelor of Arts
Adn
5

Utilization Review Nurse/lpn

Medicaid Managed Care

  • Reviewed NJ Choice and PCA tool for members to decipher medical necessity
  • Analyzed member records to ensure compliance with government and insurance company reimbursement policies
  • Determining member review dates according to established diagnostic criteria
  • Maintained utilization review logs as needed and created reviews to send to medical director
  • Perform administrative duties; create spreadsheets to log daily activities and other documents as assigned
Candidate Info
8
years in
workforce
1
year
at this job
Clinical Medical Assistant
Clinical
6

Utilization Review Nurse

Perform, monitor, and determine medical necessity reviews on inpatient and outpatient healthcare services ensuring health care services being performed in the appropriate setting

  • Ensure effective care being delivered through the use of nationally recognized criteria
  • Analyze appropriate medical benefits are applied to services reviewed for medical necessity
  • Serve as liaison between members, providers, benefits and customer service team
  • Collaborate with Medical Director and Director of Medical Management in reviewing clinically complex patients
  • Refer cases as necessary to case management to assist in management of catastrophic patients
  • Identify, initiate and perform discharge planning on clinically complex patients effectively decreasing readmissions
Candidate Info
6
years in
workforce
3
years
at this job
Nursing
7

Utilization Review Nurse

To ensure the effective and efficient use of health care services.

  • Provided hospital pre-certification and concurrent medical record reviews to determine appropriateness of admissions, procedures and length of stays.
  • Provided non-inpatient case reviews to determine the medical necessity and appropriateness of treatment plans, ratings and Out-Patient Services.
  • Collaborated with multidisciplinary teams.
  • Reviewed medical records for ICD 9, CPT and DRG. Certified acute hospital length of stays as medically necessary.
  • Maintained statistical records and quarterly reports as required.
  • Represented Utilization Review Department on various committees within SCF and with external partners.
Candidate Info
30
years in
workforce
3
years
at this job
HS
Nursing
8

Case Manager / Utilization Review Nurse

Family Practice staff nurse for 4 physicians providing care to over 2,000 active duty personnel and their families. Some areas of responsibility included the management of immunizations; routine care; medication refills; referral to specialty clinics; assisting with minor procedures; scheduling; depo-medrol clinic; blood draws and patient education.

  • Obtained required credentials as a Certified Professional in Utilization Review, developed the program, provided training to physicians and other clinic staff then implemented Utilization Review and Case Management programs for the clinic.
  • Instrumental in the successful transition of the military healthcare system for active duty personnel from Supplemental Medicine paid by active duty commands to the new TriCare Healthcare System. Liaison with new network providers and hospitals to ensure correct contact information available to them to facilitate Utilization Review and timely processing of claims for payment.
  • Conducted prior-approval first level review for all requested out-patient testing and specialty review consults for active duty personnel.
  • Conducted stay reviews for all active duty personnel hospitalized in the community and facilitated transfer to military hospitals when indicated.
  • Participated in multi-disciplinary patient case management at the clinic level. Participated in multi-disciplinary case management/discharge planning at community hospitals for hospitalized active duty members. Facilitated acquisition of needed durable medical equipment and supplies for home care and coordinated follow-up appointments.
  • Developed standard of practice and competencies for telephone triage and supervised assigned staff.
Candidate Info
19
years in
workforce
4
years
at this job
HS
Leadership & Supervisor Training
BS
Nursing
9

Case Manager / Utilization Review Nurse

Determined medically necessary levels of care through on site concurrent review.

  • Authorized appropriate and cost effective level of services.
  • Proactively educated physicians and patient/caregivers regarding vendor and community service resources.
  • Coordinated in-home services post hospital discharge.
  • Initiated more effective methods of case tracking and communication with service providers.
  • Selection Committee member of pilot CHF Research Program.
Candidate Info
10
years in
workforce
2
years
at this job
BSN
Bachelor of Science in Nursing
10

Utilization Review Nurse, LVN

Provided comprehensive Utilization Review, prospectively, concurrently or retrospectively utilizing cost containment strategies

  • Determined whether all aspects of patient care, at every level, to be medically necessary and appropriate.
  • Review physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria. recommend certification of proposed treatment plan and issue authorization letters, or if not supported, refer for peer clinical review physician.
  • Compliance with established utilization review process performance expectations and standards, assuring clients receive the highest degree of professional medical accuracy.
  • Maintaining close relationships among all parties, in person and telephonically
Candidate Info
21
years in
workforce
10
years
at this job

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