A Utilization Management Nurse takes responsibility for ensuring that the healthcare services provided by the facility are administered effectively. Main job duties listed on the Utilization Management Nurse Resume are – reviewing patient clinical information, advocating quality care, finding ways to prevent patient complications, analyzing and flowcharting the inpatient admission process, maintaining accurate records of patient interactions, mentoring staff on appropriate and efficient care procedures and methods; and performing utilization review activities.
Those seeking this job role should mention on the resume the following skills and abilities – nursing expertise, clinical skills, leadership skills, problem-solving attitude; knowledge of hospital procedures and nursing administration, patient case management expertise, and a good understanding of medical claims and insurance claims. Apart from possessing a nursing degree, applicants are expected to have a license and a post-baccalaureate certificate in case management or healthcare risk management.
Objective : As a Utilization Management Nurse, responsible for Utilizing clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate healthcare services/benefits for members.
Skills : Case Management, Utilization Review, Utilization Review.
Description :
Developed and implemented a comprehensive Utilization Management plan/program in accordance with the facility's goals and objectives.
Advised senior leadership on the implementation of these goals and objectives.
Performed data/metrics collection on identified program areas.
Analyzed and trended results, including over-and underutilization of healthcare resources.
Identified areas for improvement and cost containment.
Reported utilization patterns and provides feedback in a timely manner to senior leadership staff and medical providers.
Analyzed medical referrals/appointments and general hospital procedures and regulations by monitoring specialty care referrals for appropriateness, covered benefits, and authorized surgery/medical procedures, laboratory, radiology, and pharmacy.
Experience
2-5 Years
Level
Junior
Education
Diploma
Utilization Management Nurse Resume
Summary : Utilization Management Nurse with a valid state license. Greater than 10 years of experience in utilization review, case management, and a background in medical billing and coding.
Skills : Charge Nurse Colostomy care Oxygen, Therapy data collection.
Description :
Reviewed previous and present medical care practices for patterns; trends incidents of under-or over-utilization of resources incidental to providing medical care.
Presented data to business planning functions to assist in business decisions.
Acted as referral approval authority for designated referrals per local/AF/DoD/national guidance and standards.
Performed reviews for home health services and durable medical equipment utilizing local Medicare criteria for the state of S.C.
Reviewed requests for authorization for medical necessity and precertification for private insurance companies utilizing Milliman guidelines.
Evaluated personnel, coached and disciplined staff, served as a preceptor and mentor.
Initiated referrals to ensure appropriate coordination of care.
Experience
10+ Years
Level
Senior
Education
GED
Utilization Management Nurse Resume
Objective : Highly motivated Utilization Management Nurse with drive, creativity, and a passion to find unique solutions to customer issues as well as market challenges. Strategic thinker focused on developing marketing concepts as well as tactical plans to achieve business objectives. Educated in cross-cultural business practices and intercultural issues.
Worked compensation utilization review nurse for multiple clients served by Liberty Mutual.
Determined made on proper medical care for compensable injuries covered under workers' compensation benefits.
Assisted with sending reviews to physician peer organizations to determine medical appropriateness for non-FDA approved procedures.
Cross-trained to assist in New Jersey Auto Claims UM Division Accomplishments.
Sought the advice of the Medical Director when appropriate, according to policy.
Assisted non-clinical staff in the performance of administrative reviews.
Performed comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgment, and contractual eligibility.
Experience
2-5 Years
Level
Junior
Education
BS
Utilization Management Nurse Resume
Objective : Seeking a Utilization Management Nurse position with an outstanding career opportunity that will offer a rewarding work environment along with a winning team that will fully utilize management skills.
Skills : Microsoft Office, Communication Skills, Management Skills.
Description :
Sough the advice of the Medical Director when appropriate, according to policy.
Assisted non-clinical staff in the performance of administrative reviews.
Performed comprehensive provider and member appeals, denial interpretation for letters, retrospective claim review, special review requests, and UM pre-certifications and appeals, utilizing medical appropriateness criteria, clinical judgment, and contractual eligibility.
Regulated and predictable attendance.
Maintained work area in a clean and orderly condition and ensures safe operating conditions within the area of responsibility.
Worked to encourage and promote Company culture throughout the organization - waiting on this to be approved.
Oversaw the Inpatient case management area.
Experience
2-5 Years
Level
Junior
Education
Diploma
Utilization Management Nurse Resume
Objective : Seeking a Utilization Management Nurse position in the healthcare industry in the focus areas of utilization, case management, coding, authorizations, and quality assurance. I am looking for a position outside the scope of Nursing to broaden my experiences and knowledge.
Responsible for obtaining clinical, communicating with protection companies, and case managers in order to obtain authorizations for 120 patients with private insurance needing home health care.
Conducted QA & QI monitoring every 60-days based on the recertification of the patient.
Performed in-depth Medicaid clinical reviews to submit for authorization.
Verified Insurance coverage and assessed the need for home health care.
Provided appropriate utilization of resources and assisted with documentation improvement.
Referred cases to the medical director for further review when the request does not meet medical necessity guidelines.
Communicated by phone with providers when additional information is needed to process requests or to provide notification of determination about medication requests.
Experience
2-5 Years
Level
Executive
Education
BS
Utilization Management Nurse Resume
Objective : As a Utilization Management Nurse, responsible for Working with the operation’s leadership management team to set priorities and goals for the clinical programs, ensuring utilization performance standards and compliance and quality standards are addressed and met.
Skills : Management Skills, Communication Skills, Planning SKills.
Description :
Had projects with our General Practice Manager (GPM) where we worked on streamlining and managing our beneficiary High Utilization and inappropriate ER use, with other projects identified.
Identified concerns and trending.
Assisted the SGH, Leadership with complex, complicated cases, both as Nurse Case Manager and as Utilization Manager., have utilized both external and internal resources as appropriate.
Attended Access to Care, Data Quality, PSEAC, and other meetings as requested, appropriate, provide feedback and collaboration as appropriate to identify and improve needs/concerns for betterment for services to our beneficiaries and staff.
Responsible for ensuring the UR Plan was carried out in accordance with all QIO/PRO mandates and government regulations.
Worked closely and train with the case management department to enable workload sharing across the disciplines.
Consistently demonstrated compliance with HIPAA regulations, professional conduct, and ethical practice.
Experience
2-5 Years
Level
Junior
Education
Diploma
Utilization Management Nurse Resume
Objective : Utilization Nurse is responsible for the care of patients in the hospital, outpatient departments, and other health care facilities throughout the United States. This position is responsible for managing patient and provider schedules, administering medication and other health care services as appropriate to meet patient needs, planning.
Skills : Test Administrator, Case Management, Computer.
Description :
Performed reviews for assigned patients to determine the medical necessity.
Met daily productivity of 25-30 reviews.
Handled incoming provider calls from the phone queue system.
Verified the appropriateness of service Call back providers with precertification numbers as needed and the file completed precertification requests as per established procedures.
Maintained cooperative working relationships with all ICM departments and providers.
Completed reviews in the Tricare system via Interqual.
Processed requests within the time frame allotted as per individual state guidelines and/or Center for Medicare Services (CMS) guidelines.
Experience
2-5 Years
Level
Junior
Education
BS
Utilization Management Nurse Resume
Objective : To obtain a Utilization Management Nurse position, which will allow me the opportunity to utilize my training, skills, and education, with the potential for upward mobility and to make a difference in the health of patients by providing quality care.
Performed medical necessity determination for prospective, concurrent, and retrospective cases in accordance with federal/state mandates, medical policies, and evidence-based clinical guidelines.
Responsible for screening enrollees for healthcare programs including case management and disease management.
Participated in the development, implementation, evaluation, and maintenance of the facility's Utilization Management (UM) program and other Quality Management initiatives.
Assessed the clinical content of medical records and associated documentation for quality and appropriateness of clinical care such as adherence to or deviation from accepted practice standards, guidelines, and/or procedures.
Applied the principles of InterQual and other UM criteria to reviews of clinical care.
Provided UR input for clinical and administrative staff in support of the UM program and/or new standards or initiatives.
Maintained work area in a clean and orderly condition and ensures safe operating conditions within the area of responsibility.
Experience
2-5 Years
Level
Executive
Education
MS
Utilization Management Nurse Resume
Objective : Utilization Management Nurse Highly skilled professional with 20 years experience in acute and chronic care of adults and children. Hospital, clinic, and office experience, also with experience in hospital liaison for post-acute care patients, utilization management, quality control, case management, and hospital pre-certification.
Skills : Communication SKills, Nursing, Multitasking.
Description :
Communicated and interacted appropriately and courteously with internal and external customers.
Maintained confidentiality of patient/employee information in all forms.
Effectively and professionally communicated with medical office staff to obtain pertinent patient clinical information.
Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs.
Established the need for inpatient, stay, and length of stay of acute inpatient admissions.
Identified inpatient admissions no longer meeting criteria and referred inpatient admission cases to the Medical Director for evaluation.
Included telephonic triage of referrals, inpatient hospital admits computer documentation of admits and referrals, interact with physicians.
Experience
2-5 Years
Level
Executive
Education
MS
Utilization Management Nurse Resume
Objective : Maintaining a Utilization Management Nurse professional composure and effectiveness in Rehabilitation, private practices, utilization management, and long term care nursing, making decisions in fast-paced, unpredictable, and stressful environments. Interfacing seamlessly with doctors, specialized support services, pharmacists, patients, and visiting families.
Creating an account is free and takes five seconds.
You'll get access to the PDF version of this resume template.
Choose an option.
Sign up with Google
Sign up with Facebook
Sign up with Linkedin
This helps us make sure you're human and prevents spammers from abusing our services.
By continuing, you agree to our Privacy Policy and Terms.
Unlock the Power of Over 10,000 Resume Samples.
Take your job search to the next level with our extensive collection of 10,000+ resume samples. Find inspiration for your own resume and gain a competitive edge in your job search.
Get Hired Faster with Resume Assistant.
Make your resume shine with our Resume Assistant. You'll receive a real-time score as you edit, helping you to optimize your skills, experience, and achievements for the role you want.
Get Noticed with Resume Templates that Beat the ATS.
Get past the resume screeners with ease using our optimized templates. Our professional designs are tailored to beat the ATS and help you land your dream job.
