Nurse Reviewer Resume
Summary : As a Nurse Reviewer reviewed and interpreted medical records and compared them against criteria to determine appropriateness and reasonableness of care, applied critical thinking and decision-making skills to determine if the medical record documentation supports the need for service while maintaining production goals and quality standards.
Skills : Clinical Knowledge, Critical Thinking.
Description :
- Documented decisions and rationale to justify review findings or no findings.
- Determined approval or initiates a referral to the physician consultant and processes physician consultant decisions ensuring the reason for the denial is described in sufficient detail and completed within the contractual deadline.
- Performed prior authorization, precertification, and retrospective reviews.
- Prepared decision letters as needed in support of the utilization review contract.
- Assisted management with training new Nurse Reviewers to include daily monitoring, mentoring, feedback, and education.
- Maintained current knowledge of clinical criteria guidelines and completes required CEUs to maintain RN license.
- Actively cross-trained to perform reviews of multiple claim types to provide a flexible workforce to meet client needs.
Experience
10+ Years
Level
Senior
Education
Registered Nurse
Nurse Reviewer Resume
Summary : As a Nurse Reviewer, worked during normal business hours as this position requires frequent interactions with the team and other departments within the company.
Skills : Attention to Detail, Communication Skills.
Description :
- Assisted in developing best practices and guidelines for medical record review and data collection.
- Facilitated quality improvement plan development and implementation as requested, both internally and with external customers.
- Provided supporting reference documentation to the reviewer.
- Fostered and promoted continuity of care and cooperative partnerships by liaising with healthcare providers, acute care hospitals, and other programs/organizations involved in the provision of services.
- Complied with established departmental policies, procedures, and objectives.
- Stayed abreast and complied with state/federal legislation as it applies to utilization management services.
- Recommended, tested, and implemented process improvements, new audit concepts, and technology improvements that will enhance production, quality, and client satisfaction.
Experience
7-10 Years
Level
Management
Education
Bachelor of Science in Nursing
Nurse Reviewer Resume
Headline : As a Nurse Reviewer, provided leadership, oversight, and guidance to team members to ensure quality products for customers, and maintained ongoing communication with the claims examiner/adjustor as to the status of determination.
Skills : Decision-Making, Medical Coding.
Description :
- Acted as a clinical resource to non-clinical staff, and stayed abreast of the healthcare industry's current practices and trends.
- Participated in performance improvement initiatives and demonstrated the use of quality improvement in daily operations.
- Maintained positive working relationships with Members, and relevant informal supports, provider organizations, and state agencies.
- Rendered medical necessity determinations for Medicare QIC Part A cases assigned.
- Resolved all other technical issues within the Medicare reconsideration assigned.
- Reviewed cases to determine and summarize facts of each case assigned and assessed issues involved in the case.
- Supported Part A party hearings providing clinical testimony to party hearings.
Experience
5-7 Years
Level
Executive
Education
Bachelor of Science in Nursing
Nurse Reviewer Resume
Objective : As a Nurse Reviewer, performed other special projects unrelated to a specific case such as general legal research, general medical research, drafting proposal sections, or acting as a liaison for a specific project, when necessary, analyzed and evaluated medical information, and provided good customer service skills.
Skills : Regulatory Compliance, Documentation Skills.
Description :
- Worked independently to meet predefined production and quality standards.
- Worked proficiently with Microsoft Word, Excel, and PowerPoint.
- Worked knowledge in and successful application of basic level of health care data analysis and clinical review.
- Successfully prioritized multiple tasks, and provided good customer service skills.
- Medically reviewed, charted audits, and quality improvement processes.
- Attended training and scheduled meetings to enhance skills and working knowledge of clinical policies, procedures, rules, and regulations.
- Ensured development and design of data collection forms were by study protocol and established standards.
Experience
2-5 Years
Level
Executive
Education
Registered Nurse (RN)
Senior Nurse Reviewer Resume
Summary : As a Senior Nurse Reviewer, conducted initial medical necessity review of out-of-network preauthorization requests for services requested outside of the client health plan network.
Skills : Computer Proficiency, Time Management.
Description :
- Maintained confidentiality of patient and provider-specific information.
- Developed telephone service standards to meet departmental performance metrics.
- Received pre-authorization requests from front-line intake.
- Notified ordering physician or rendering service provider office of the pre-authorization determination decision.
- Documented the results of the initial clinical review and determination in the pre-certification computer system.
- Reviewed clinical evaluations and eligibility determinations submitted by providers and plans for purposes of confirming eligibility.
- Served as clinical subject matter expert on strategic projects, such as the Uniform Core Assessment, development of key performance indicators, or other projects as assigned.
Experience
10+ Years
Level
Senior
Education
Registered Nurse
Junior Nurse Reviewer Resume
Objective : As a Junior Nurse Reviewer, experienced with medical record review of short-stay inpatient acute care admissions, and experienced applying MCG for inpatient level of care determinations.
Skills : Collaboration, Ethical Conduct.
Description :
- Received preauthorization requests from front-line intake.
- Conducted initial medical necessity clinical screening.
- Determined if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review.
- Monitored and evaluated patients’ plans of care and identified potential issues through telephonic outreach.
- Recommended appropriate interventions.
- Received requests for pre-certification of procedures via telephone, fax, or Web.
- Prepared enforcement packets for citations in which Section 12 enforcements are recommended.
Experience
2-5 Years
Level
Junior
Education
Bachelor of Science in Nursing
Assistant Nurse Reviewer Resume
Objective : As an Assistant Nurse Reviewer, reviewed potential Immediate Jeopardy/ Substandard Quality of Care situations in nursing and rehabilitation facilities.
Skills : Ethical Conduct, Problem-Solving.
Description :
- Experienced with CMS clinical review guidelines for Medically Necessary inpatient admission.
- Performed clinical and medical reviews, data collection, and database entry.
- Assured that all work was completed within contractual deadlines and that all components of the completed review were present.
- Delivered the final product to the client per client-specific contractual guidelines.
- Performed retrospective chart review per contract specifications.
- Evaluated, identified, and reported on, quality of care issues.
- Conducted on-site reviews and assessments of members’ community long-term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorized services for Members per program guidelines and regulations.
Experience
2-5 Years
Level
Executive
Education
Bachelor of Science in Nursing
Nurse Reviewer Resume
Headline : As a Nurse Reviewer, Providing clinical support to OLTSS program teams in the day-to-day management of their programs, in the form of reviewing critical incident reports, advising on quality improvement and performance measurement initiatives, responding to providers on clinical issues, assisting with hard-to-place MassHealth members, and advising on clinical impact of changes to regulations and medical necessity criteria.
Skills : Clinical assessment, Documentation.
Description :
- Assisted in the preparation of Risk Adjustment Data Validations (RADV) audits.
- Facilitated the Informal Dispute Resolution/ Independent Informal Dispute Resolution process, and reviewed Statements of Deficiencies written across NYS for quality assurance purposes.
- Prepared Character and Competency reviews, review and assist in developing policies and procedures.
- Assisted in answering questions from the general public.
- Prepared and evaluated various reports for quality assurance functions.
- Completed any additional assignments as deemed necessary by the Director.
- Conducted site and desk audits of LTSS providers and integrated care plans to evaluate the quality of care, medical necessity, program eligibility, health and safety, care planning, clinical documentation, staffing, and compliance with MassHealth regulations.
Experience
5-7 Years
Level
Executive
Education
Registered Nurse
Nurse Reviewer Resume
Summary : As a Nurse Reviewer, conducted comprehensive reviews of medical records to evaluate the appropriateness and necessity of healthcare services provided, utilized clinical expertise to assess the quality of care, identified potential gaps in treatment plans, and recommended interventions to improve patient outcomes.
Skills : Regulatory compliance, Healthcare standards.
Description :
- Collaborated with healthcare providers, including physicians and specialists, to obtain additional information and clarify discrepancies in medical records.
- Ensured compliance with industry standards, insurance policies, and regulatory requirements in the review process.
- Communicated findings to the appropriate stakeholders, including healthcare providers and insurance claim representatives.
- Participated in the development and implementation of utilization management strategies to optimize resource allocation and reduce unnecessary healthcare costs.
- Stayed current with changes in healthcare regulations, coding systems, and reimbursement policies.
- Directed patient care, including assessment, medication administration, and coordination of care plans.
- Conducted patient education on treatment plans, medications, and self-care practices.
Experience
7-10 Years
Level
Management
Education
Registered Nurse
Nurse Reviewer Resume
Objective : As a Nurse Reviewer, updated internal systems used for tracking and reporting of findings, including but not limited to, patient accounting systems, spreadsheets, and databases, to facilitate monthly management reporting.
Skills : Strong analytical, Problem-solving skills.
Description :
- Developed and maintained professional working relationships with internal and external stakeholders to facilitate continuous process improvement as it relates to audit activity and findings.
- Provided subject matter knowledge on various billing, coding, and clinical topics to the audit representatives and other key customers as needed
- Participated in MGB internal projects, experienced in healthcare quality management and utilization review.
- Tracked records in assessing medical records, conducting clinical reviews, and ensuring compliance with regulatory standards.
- Contributed my expertise in improving healthcare delivery and patient outcomes.
- Communicated areas of identified opportunities for revenue improvement to Revenue Integrity leadership,
- Experienced working with cross-functional areas and teams, experienced using Microsoft suite (Excel, Access, Word, and Microsoft project).
Experience
2-5 Years
Level
Executive
Education
Registered Nurse
