Utilization Review Nurse Resume
Objective : Compassionate Utilization Review Nurse with over 2 years of experience in healthcare settings, skilled in evaluating treatment plans and ensuring compliance with medical standards. Adept at collaborating with multidisciplinary teams to enhance patient care while optimizing resource utilization. Committed to delivering high-quality, cost-effective healthcare solutions that meet diverse patient needs.
Skills : Utilization Review Expertise, Clinical Assessment Skills, Critical Thinking In Care Management, Clinical Documentation Proficiency
Description :
- Collaborated with healthcare providers to optimize patient care outcomes and resource utilization.
- Utilized clinical guidelines to assess treatment appropriateness and accurately interpret insurance benefits.
- Directed members to suitable healthcare providers and community resources, enhancing care accessibility.
- Applied clinical expertise in coordinating care with facilities and providers.
- Engaged with medical directors to ensure accurate claims processing and appropriateness of care.
- Conducted pre-certification and retrospective reviews to ensure compliance with established standards.
- Facilitated member access to necessary healthcare services while maintaining cost-effectiveness.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Utilization Review Nurse Specialist Resume
Objective : Dedicated Utilization Review Nurse Specialist with 5 years of experience in healthcare, proficient in evaluating treatment plans and ensuring adherence to medical guidelines. Expert in collaborating with interdisciplinary teams to optimize patient care and resource management. Passionate about implementing effective healthcare solutions that enhance patient outcomes and operational efficiency.
Skills : Patient Care Coordination, Data Analysis And Reporting, Quality Assurance, Data Analysis, Regulatory Compliance
Description :
- Authorize cases based on established criteria to ensure optimal patient outcomes across various care settings.
- Review pre-certification requests and perform comprehensive inpatient and outpatient evaluations.
- Maintain up-to-date knowledge of policies and procedures for medical and behavioral health services.
- Utilize established criteria to assess medical necessity and appropriateness of care.
- Refer high-risk cases to the case management team for comprehensive support.
- Evaluate social, economic, and emotional factors impacting patient recovery and adjust care plans accordingly.
- Collaborate with multidisciplinary teams to identify and address social determinants affecting patient health.
Experience
2-5 Years
Level
Junior
Education
BSN
Utilization Review Nurse Resume
Objective : Dynamic Utilization Review Nurse with 2 years of experience in assessing medical necessity and ensuring compliance with established guidelines. Proficient in collaborating with healthcare teams to optimize patient outcomes and resource utilization. Driven to provide high-quality care solutions that align with patient needs and organizational goals.
Skills : Healthcare Documentation, Home Health Care, Presentation Skills, Clinical Assessment, Interpersonal Skills, Conflict Resolution
Description :
- Conduct comprehensive reviews of treatment plans for preauthorization, ensuring alignment with clinical guidelines.
- Document clinical information accurately in the prior authorization system to support decision-making.
- Engage in continuous training to maintain compliance with healthcare standards and regulations.
- Foster a therapeutic environment for patients and families, ensuring adherence to safety protocols.
- Encourage a positive workplace culture by supporting team members and embracing innovative ideas.
- Contribute to quality improvement projects aimed at enhancing healthcare delivery and patient outcomes.
- Ensure compliance with departmental policies, performance improvement initiatives, and infection control standards.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Utilization Review Nurse Consultant Resume
Headline : Skilled Utilization Review Nurse Consultant with 7 years of extensive experience in assessing clinical necessity and optimizing care pathways. Proficient in collaborating with healthcare teams to ensure compliance with regulatory standards while enhancing patient outcomes. Committed to leveraging analytical skills to drive healthcare efficiency and quality improvements across diverse settings.
Skills : Care Coordination, Facets For Claims Processing, Cms Compliance Guidelines, Time Management And Prioritization, Telehealth And Remote Review, Cost Containment And Quality Assurance
Description :
- Gathered comprehensive clinical histories and treatment plans to assess medical necessity for insurance authorizations.
- Conducted ongoing evaluations of patient cases, transitioning individuals out of case management when optimal health status is reached.
- Reviewed cases against physician-developed criteria and referred non-compliant cases to the Medical Panel.
- Established quality review dates based on client-specific guidelines to ensure timely assessments.
- Utilized clinical judgment alongside established guidelines to evaluate medical necessity and compliance.
- Performed accurate verification of eligibility, benefits, and coverage for pre-certification processes.
- Collaborated with healthcare providers to optimize treatment plans and resource utilization.
Experience
5-7 Years
Level
Senior
Education
BSN
Utilization Review Nurse Resume
Objective : Experienced Utilization Review Nurse with 2 years of expertise in assessing medical necessity and compliance with healthcare regulations. Skilled in collaborating with healthcare teams to enhance patient care and streamline resource utilization. Passionate about driving quality outcomes and improving operational efficiency while adhering to industry standards.
Skills : Patient Advocacy, Critical Thinking, Risk Assessment, Resource Management, Communication Skills, Problem Solving
Description :
- Reviewed complex clinical and medical procedure requests, referring to the medical director when necessary.
- Ensured confidentiality and compliance with HIPAA regulations during the review of medical documentation.
- Requested clinical information and provided Utilization Review determinations verbally and in writing.
- Processed preauthorization requests using critical thinking and strong communication skills.
- Fostered positive relationships with co-workers, adjustors, providers, and non-medical staff.
- Exceeded accuracy and quality standards while effectively managing caseloads.
- Reviewed clinical documentation to inform utilization review and precertification determinations.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Utilization Management Nurse Resume
Objective : Resourceful Utilization Management Nurse with 2 years of experience in healthcare environments, proficient in assessing treatment plans for compliance with medical standards. Skilled in fostering communication among multidisciplinary teams to enhance patient care and ensure optimal resource utilization. Eager to contribute to quality improvement initiatives that align with patient and organizational goals.
Skills : Strong Organizational Skills, Effective Interpersonal Communication Skills, Proficient In Electronic Health Records, Telehealth Proficiency
Description :
- Conduct comprehensive reviews of patient care for medical necessity and appropriateness.
- Recommend alternatives to traditional healthcare to medical directors and network physicians.
- Engage with the primary care nurse to monitor critical pathways.
- Maintain open communication channels among enrollees, hospitals, and community care providers.
- Coordinate information sharing with payers and providers to ensure efficient care delivery.
- Initiate conferences with healthcare team members regarding post-hospital care planning.
- Collaborate with healthcare teams to ensure optimal patient outcomes and resource utilization.
Experience
0-2 Years
Level
Fresher
Education
BSN
Utilization Review Nurse Resume
Objective : Dedicated Utilization Review Nurse with over 5 years of experience in assessing patient care plans and ensuring compliance with healthcare regulations. Proven ability to collaborate with multidisciplinary teams to optimize patient outcomes while managing costs. Strong analytical skills and attention to detail, adept at identifying areas for improvement in care delivery and resource utilization.
Skills : Basic Life Support Certification, Interdisciplinary Collaboration, Dependability, Health Insurance Knowledge, Patient Education, Documentation Skills
Description :
- Coordinated mental health services with clinics and community resources to ensure comprehensive care.
- Developed policies and guidelines for monitoring contracted agency performance in mental health treatment.
- Conducted clinical record audits to assess compliance with treatment contracts.
- Compiled data and prepared reports for performance monitoring of in-network providers.
- Managed sensitive investigations related to complaints from state officials, ensuring thorough resolution.
- Communicated findings of investigations to relevant regulatory agencies and stakeholders.
- Maintained up-to-date knowledge of healthcare regulations and best practices in utilization review.
Experience
2-5 Years
Level
Junior
Education
BSN
Utilization Review Nurse Advisor Resume
Headline : Accomplished Utilization Review Nurse Advisor with 7 years of experience in evaluating treatment plans and ensuring compliance with healthcare regulations. Expertise in collaborating with multidisciplinary teams to enhance patient outcomes while optimizing resource allocation. Passionate about implementing strategic healthcare solutions that promote efficiency and improve the quality of care.
Skills : Utilization Management, Data Interpretation, Healthcare Policy Knowledge, Health Policy Knowledge, Health Informatics, Evidence-based Practice
Description :
- Promote and restore patient health by identifying care requirements and implementing effective treatment plans.
- Document findings and collaborate with physicians and multidisciplinary teams to ensure optimal patient support.
- Review medical records to assess necessity based on established Milliman Criteria.
- Facilitate safe discharge planning by obtaining and reviewing members' medical records.
- Evaluate outpatient services for medical necessity and negotiate rates with participating providers.
- Conduct concurrent reviews of clinical information to determine appropriate care settings.
- Adhere to standards of care, ensuring compliance with governing regulations and enhancing patient quality of care.
Experience
5-7 Years
Level
Senior
Education
BSN
Utilization Review Nurse Resume
Summary : Dedicated Utilization Review Nurse with a decade of experience in assessing medical necessity and ensuring compliance with healthcare standards. Expertise in collaborating with interdisciplinary teams to enhance patient care and optimize resource utilization. Committed to leveraging analytical skills to drive quality improvements and achieve positive patient outcomes.
Skills : Analytical Assessment Capabilities, Effective Team Collaboration, Healthcare Policies, Data Presentation Skills, Risk Management, Chart Review
Description :
- Conduct concurrent reviews of clinical data to assess medical necessity and appropriateness of treatment plans based on Interqual criteria.
- Monitor patient progress daily and communicate updates effectively to insurance providers.
- Ensure continuity of care from admission to discharge, optimizing treatment levels based on patient needs.
- Facilitate transitions from acute care to lower levels of care in a timely manner.
- Collaborate with healthcare professionals to evaluate patients' medical conditions for safe discharge planning.
- Work with Nurse Navigators to identify and mitigate frequent hospital readmissions.
- Act as a liaison among patients, families, and healthcare teams to enhance care delivery.
Experience
7-10 Years
Level
Management
Education
BSN
Nurse Reviewer Resume
Objective : As a dedicated Nurse Reviewer with 2 years of experience, I specialize in assessing treatment plans for medical necessity and compliance with healthcare standards. My strong analytical skills enable effective collaboration with healthcare teams to enhance patient outcomes. I am committed to implementing quality improvement initiatives that drive efficiency and optimize resource utilization.
Skills : Strong Organizational Abilities, Proficient In Emr Systems, Team Leadership, Cultural Competence
Description :
- Conduct comprehensive reviews of requested medical treatments for necessity and appropriateness, ensuring adherence to clinical guidelines.
- Evaluate patient services to confirm compliance with established medical standards and regulatory requirements.
- Utilize critical thinking to make informed decisions in complex cases, demonstrating sound clinical judgment.
- Oversee telephonic case management for Workers Compensation claims, coordinating all aspects of injured worker care.
- Maintain meticulous documentation to uphold high standards of accuracy and detail in patient records.
- Engage with strategic partners to gather and clarify essential clinical information for review processes.
- Analyze clinical data against established criteria to determine the appropriateness of care and authorize necessary medical interventions.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Utilization Review Nurse Resume
Headline : Compassionate and detail-oriented Utilization Review Nurse with extensive experience in evaluating patient care for quality and efficiency. Skilled in conducting thorough reviews of medical records and treatment plans to ensure adherence to clinical guidelines. Excellent communication skills, fostering collaboration between healthcare providers and insurance companies to facilitate optimal patient care.
Skills : Advanced Clinical Assessment, Healthcare Resource Management, Decision Making, Insurance Knowledge, Resource Allocation
Description :
- Conduct comprehensive concurrent and retrospective reviews to ensure medical necessity and adherence to guidelines.
- Utilize clinical judgment to apply Severity of Illness and Intensity of Service criteria effectively.
- Collaborate with interdisciplinary teams to address post-acute care needs and optimize patient transitions.
- Prepare and submit timely denials, referrals, and documentation per departmental policies.
- Evaluate medical records for transplant eligibility and coordinate with medical directors for case reviews.
- Process requests for DME, home health care, and other ancillary services efficiently.
- Notify medical directors of high-cost cases for tracking and review purposes.
Experience
5-7 Years
Level
Senior
Education
BSN
Prior Authorization Nurse Resume
Summary : With a decade of nursing experience, I specialize in prior authorization processes and medical necessity evaluations. My expertise lies in collaborating with healthcare providers and insurance companies to facilitate timely approvals and enhance patient outcomes. I am dedicated to optimizing resource utilization while ensuring compliance with regulatory standards, consistently improving care delivery.
Skills : Stress Management, Health Records Management, Clinical Guidelines, Training And Mentoring, Patient Care Plans, Telehealth Services
Description :
- Served as the key liaison among patients, healthcare providers, and insurance companies to facilitate prior authorization requests.
- Advocated for patient needs within the healthcare delivery system, ensuring timely access to necessary treatments.
- Reviewed and analyzed claims for medical necessity and appropriateness, improving patient outcomes through efficient resource management.
- Oversaw utilization and quality management to enhance service delivery and patient care.
- Identified trends in claim issues, providing insights for targeted education and intervention strategies.
- Ensured compliance with healthcare regulations and standards during claim assessments and evaluations.
- Engaged with interdisciplinary teams to optimize treatment plans and enhance overall patient care.
Experience
7-10 Years
Level
Management
Education
BSN
Utilization Review Nurse Resume
Objective : Results-driven Utilization Review Nurse with a solid background in clinical nursing and healthcare management. Expertise in reviewing and analyzing patient data to determine the necessity and appropriateness of care services. Committed to improving patient care quality while reducing unnecessary costs, with a strong focus on compliance and regulatory standards in healthcare.
Skills : Clinical Evaluation, Team Collaboration, Adult And Pediatric Care, Nursing Process, Patient Safety, Discharge Planning
Description :
- Conducted thorough reviews of precertification requests to verify medical necessity.
- Monitored daily clinical data for concurrent reviews, extending stays when clinically justified.
- Coordinated care plans aimed at improving quality of life and preventing unnecessary hospitalizations.
- Supervised nursing staff in prioritizing authorization notifications to ensure timely communication with providers.
- Provided guidance to nurses on identified issues, fostering effective problem-solving strategies.
- Oversaw utilization management queues to meet established performance metrics and improve efficiency.
- Performed utilization and concurrent reviews using Milliman criteria, ensuring quality performance audits of practitioners.
Experience
0-2 Years
Level
Entry Level
Education
BSN
Utilization Review Nurse Resume
Summary : Accomplished Utilization Review Nurse with 10 years of extensive experience in evaluating treatment plans and ensuring compliance with healthcare standards. Expert in collaborating with multidisciplinary teams to enhance patient outcomes and optimize resource management. Committed to implementing strategic healthcare solutions that drive quality improvements and maximize efficiency.
Skills : Advanced Organizational Skills, Strong Interpersonal Communication Skills, Attention To Detail, Negotiation Skills, Report Writing
Description :
- Document findings and recommendations in a clear and concise manner.
- Ensure patient admissions comply with Medicare by utilizing Milliman Care Guidelines.
- Review electronic and paper charts to validate admission stay criteria and medical necessity.
- Monitor patient progress and adjust care plans as necessary based on reviews.
- Analyze data to identify trends affecting care delivery and patient placement.
- Communicate with insurance companies to secure authorizations for hospitalizations and advanced imaging, achieving maximum reimbursement.
- Notify third-party payors, including state Medicaid programs, through online platforms.
Experience
7-10 Years
Level
Management
Education
BSN
Concurrent Review Nurse Resume
Summary : Seasoned Concurrent Review Nurse with a decade of experience in evaluating medical necessity and optimizing patient care across various healthcare settings. Demonstrates expertise in collaborating with interdisciplinary teams to ensure compliance with regulatory standards. Passionate about leveraging clinical insights to drive quality improvements and enhance patient outcomes.
Skills : Treatment Planning, Collaboration Skills, Time Management, Medical Terminology
Description :
- Utilized clinical expertise to assess and coordinate care for members in acute, skilled, and long-term care settings.
- Conducted thorough reviews of inpatient admissions and facilitated effective discharge planning.
- Gathered critical clinical information to determine ongoing care needs and ensure optimal service delivery.
- Collaborated with physicians and healthcare teams to coordinate comprehensive care across the continuum.
- Performed concurrent and retrospective reviews for inpatient and home health services, ensuring adherence to standards.
- Monitored utilization reports to verify compliance with regulatory requirements and turnaround times.
- Addressed care issues with leadership to improve care management strategies.
Experience
7-10 Years
Level
Management
Education
BSN
Concurrent Review Nurse Resume
Headline : Dedicated Concurrent Review Nurse with 7 years of expertise in evaluating medical necessity and coordinating patient care across diverse healthcare settings. Proficient in utilizing clinical judgment to ensure compliance with regulations while optimizing resource utilization. Committed to enhancing patient outcomes through effective collaboration with multidisciplinary teams and strategic healthcare solutions.
Skills : Analytical Problem-solving Skills, Ethical Judgment, Strong Multitasking Abilities, Effective Communication Proficiencies, Statistical Analysis, Crisis Intervention
Description :
- Implemented and coordinated utilization management functions for preauthorization of outpatient procedures, surgeries, and inpatient admissions.
- Educated providers on authorization processes, collaborating with physicians to gather necessary information for utilization management.
- Ensured medical necessity and appropriateness of healthcare resources through comprehensive reviews of service requests using clinical judgment.
- Negotiated medical record review outcomes with facilities, facilitating efficient communication and resolution.
- Prepared timely notification letters regarding service denials and negotiated days, adhering to established guidelines.
- Identified safe, effective alternatives to inpatient care for patients requiring pre-hospital interventions.
- Managed transitional care negotiations when requested services did not meet acute care criteria.
Experience
5-7 Years
Level
Senior
Education
BSN
Concurrent Review Nurse Resume
Objective : Results-driven Utilization Review Nurse with a solid background in clinical nursing and healthcare management. Expertise in reviewing patient records, assessing treatment plans, and ensuring adherence to insurance guidelines. Committed to improving patient outcomes through effective resource management and quality assurance initiatives, with a focus on cost-effective care delivery.
Skills : Healthcare Informatics, Patient Management Systems, Clinical Guidelines Adherence, Outcome Measurement, Patient Follow-up, Referral Management
Description :
- Conducted comprehensive reviews of patient charts from acute care facilities to determine medical necessity for inpatient stays and services.
- Collaborated with experienced nursing staff to enhance understanding of concurrent review processes.
- Extracted and analyzed clinical data for presentations to medical directors, ensuring accurate decision-making.
- Improved attention to detail and professionalism in communications with healthcare facilities.
- Processed approvals and denials for Medicaid members with complex health conditions, ensuring adherence to guidelines.
- Presented clinical data effectively to medical directors, facilitating optimal care decisions for Medicaid members.
- Identified ongoing care needs early in inpatient stays to streamline discharge processes.
Experience
2-5 Years
Level
Junior
Education
BSN
Concurrent Review Nurse Resume
Summary : Highly skilled Concurrent Review Nurse with 10 years of diverse experience in evaluating medical necessity and coordinating patient care. Proficient in collaborating with multidisciplinary teams to ensure compliance with healthcare regulations while enhancing patient outcomes. Driven to implement strategic solutions that optimize resource utilization and improve overall healthcare delivery.
Skills : Healthcare Data Analysis, Quality Improvement, Utilization Review Software, Interqual Criteria Utilization, Utilization Review, Empathy
Description :
- Conducted comprehensive eligibility reviews for inpatient Medicaid requests, adhering to NCQA guidelines.
- Performed utilization reviews in line with state and federal regulations to ensure appropriate patient care.
- Collaborated with medical staff to finalize discharge plans, enhancing transition of care.
- Authorized inpatient stays based on clinical necessity and medical guidelines.
- Coordinated medical reviews for denied inpatient stays, facilitating appeals as necessary.
- Executed preadmission reviews for skilled nursing facilities, long-term acute care hospitals, and rehabilitation units.
- Utilized InterQual criteria to support inpatient requests, ensuring adherence to best practices.
Experience
7-10 Years
Level
Management
Education
BSN
