A utilization Review Specialist is hired to provide quality assurance to patients within medical fields. The most common work activities depicted on Utilization Review Specialist Resume include the following – performing quality control related to patient treatment, ensuring staff is properly provided to patient-s, interviewing patients and their families, reporting to designated managers in case of reportable conditions or critical incidents; modifying patient care plans after reviewing medical chart and history, auditing patient records and investigating questionable claims.
Professionals for this post should have the ability to follow the privacy laws of the patients and keep themselves updated with the latest happenings by participating in training or conference classes, they should have the ability to mentor juniors, and demonstrate proficiency in relevant software applications. College education in social work, psychology, criminal justice or sociology is the minimum requirement, but some employers accept a substantial amount of experience in lieu of a degree.
Summary : With a decade of experience in utilization review, I excel at evaluating patient care for compliance with insurance guidelines. My expertise includes applying clinical criteria to ensure appropriate resource allocation. I am committed to enhancing patient outcomes while minimizing costs through strategic oversight and collaboration with healthcare teams.
Skills : Clinical Evaluation, Clinical Assessment, Medical Coding, Insurance Verification
Description :
Provided comprehensive health assessments and patient education to ensure understanding of treatment plans.
Facilitated wellness programs and coordinated appropriate medical equipment for patient needs.
Conducted thorough assessments for hospital readmissions, ensuring compliance with healthcare standards.
Assisted in navigating barriers to care for patients and families, enhancing access to services.
Streamlined referral processes, ensuring timely medical access and resource allocation.
Collaborated with healthcare teams to address patient concerns and optimize care delivery.
Maintained accurate documentation of patient interactions and assessments for quality assurance.
Summary : Bringing a decade of specialized experience in utilization review, I adeptly assess patient care against insurance standards and clinical criteria. My focus is on optimizing resource allocation and driving improvements in patient outcomes through effective collaboration with healthcare teams.
Skills : Critical Thinking Skills, Documentation Skills, Communication Skills, Team Collaboration, Time Management
Description :
Conduct comprehensive reviews of patient care for medical necessity and appropriateness.
Analyze clinical documentation to ensure compliance with regulatory standards.
Collaborate with healthcare providers to gather necessary patient information.
Utilize clinical guidelines to assess treatment plans and outcomes.
Trained new Utilization Review staff on InterQualâ„¢ standards, enhancing team performance.
Identify opportunities for cost savings through effective resource management.
Generated utilization management reports that identified performance measures not being met, driving quality improvement initiatives.
Collaborated daily with providers, nursing staff, and Physician Utilization Management Advisors to enhance patient care pathways.
Experience
7-10 Years
Level
Management
Education
BSN
Utilization Review Specialist I Resume
Objective : Dedicated Utilization Review Specialist with over 5 years of experience in assessing patient care compliance with insurance protocols. Skilled in applying clinical criteria for effective resource management and advocating for optimal patient outcomes. Proven ability to collaborate with multidisciplinary teams to streamline processes and enhance service delivery.
Communicated critical patient information to healthcare teams, ensuring timely interventions and appropriate care.
Collaborated with clinical teams to document care manager inquiries in the clinical record accurately.
Assisted admissions in evaluating placement criteria based on clinical needs and insurance requirements.
Negotiated with insurance payers to advocate for necessary patient treatments and services.
Managed denial appeals and conducted physician reviews to uphold high-quality care standards.
Executed all responsibilities promptly, maintaining availability as needed for urgent matters.
Identified and reported care quality variances using ASAM and medical necessity standards.
Experience
2-5 Years
Level
Junior
Education
BSN
Utilization Review Specialist III Resume
Summary : A seasoned Utilization Review Specialist with 10 years of expertise in evaluating healthcare services for compliance with insurance regulations. Proven track record in applying clinical guidelines to optimize patient care and resource allocation. Committed to fostering collaboration among healthcare teams to enhance patient outcomes while effectively managing costs.
Skills : Clinical Communication, Regulatory Compliance, Care Coordination, Quality Assurance, Case Management
Description :
Managed incoming calls and processed claims to enhance operational efficiency.
Evaluated contract and benefit eligibility, providing authorizations for admissions and pre-certifications.
Collaborated with clinical reviewers for cases needing in-depth analysis.
Performed data entry of referral requests into the Utilization Management system per plan specifications.
Responded to inquiries from clients and healthcare providers, ensuring timely information delivery.
Authorized initial treatment sessions based on clinical guidelines.
Analyzed benefit coverage for facility-based treatment while maintaining positive client relations.
Experience
10+ Years
Level
Senior
Education
BSN
Utilization Review Specialist II Resume
Headline : Seasoned Utilization Review Specialist with 7 years of comprehensive experience in evaluating patient care against clinical and insurance standards. Proficient in resource allocation and ensuring compliance through meticulous reviews. Passionate about enhancing patient outcomes and fostering collaboration within healthcare teams to streamline processes and optimize care delivery.
Conducted thorough reviews of medical documentation to ensure compliance with insurance guidelines.
Collaborated with healthcare providers to determine the most suitable transport and medical services for patients.
Audited provider billing to ensure accuracy and compliance with service delivery.
Reviewed medical necessity forms to assess eligibility for services.
Assisted in recertifying standing orders based on clinical needs.
Coordinated out-of-state trip requests by liaising with physicians and case managers.
Managed reimbursement processes for enrollees, ensuring timely and accurate payments.
Experience
5-7 Years
Level
Executive
Education
BSN
Utilization Review Specialist/Executive Resume
Headline : Accomplished Utilization Review Specialist with 7 years of extensive experience in evaluating patient care against clinical guidelines and insurance protocols. Proficient in ensuring compliance and optimizing resource allocation to enhance patient outcomes. Dedicated to fostering effective communication with healthcare teams and streamlining processes to support quality care and cost efficiency.
Skills : Pharmaceutical Review, Data Analysis, Critical Thinking, Interpersonal Skills
Description :
Authorized cases in accordance with established approval processes, ensuring timely and accurate evaluations.
Documented clinical and non-clinical information to facilitate the utilization and case management processes.
Communicated effectively with members and providers, maintaining detailed records of case management activities.
Ensured compliance with regulatory timelines to uphold state and federal requirements.
Secured authorizations from insurance providers for acute inpatient mental health services.
Conducted concurrent reviews for continued authorizations, performing thorough chart audits.
Monitored patient status with insurance companies to obtain necessary authorizations for ongoing care.
Experience
5-7 Years
Level
Executive
Education
BSN
Utilization Review Specialist III Resume
Summary : Leveraging a decade of experience in utilization review, I specialize in assessing patient care for compliance with insurance standards. My proficiency in clinical criteria application drives effective resource management and enhances patient outcomes. I thrive in collaborative environments, ensuring optimal care delivery while maintaining cost efficiency.
Collaborated with healthcare teams to assess patient care against insurance guidelines, ensuring compliance.
Developed and implemented appeals for reimbursement, effectively managing financial constraints.
Instrumented the hospital's Designated Status with Blue Cross, resulting in improved resource access.
Facilitated educational sessions for staff, enhancing knowledge of utilization review processes.
Resolved complex billing issues, resulting in financial recovery for clients and improved satisfaction.
Worked with risk management to identify potential litigation risks, reducing overall hospital liability.
Maintained comprehensive records of patient interactions and financial assistance options.
Experience
10+ Years
Level
Senior
Education
BSN
Lead Utilization Review Specialist Resume
Summary : Bringing a wealth of experience in utilization review, I am skilled in evaluating patient care for adherence to insurance standards and clinical guidelines. My focus lies in optimizing resource utilization while enhancing patient outcomes through strategic collaboration with healthcare teams. I am dedicated to ensuring compliance and driving efficiencies in the review process.
Skills : Critical Thinking And Problem Solving, Icd Coding, Ehr Proficiency, Telehealth Services, Cost Management
Description :
Collaborated with RNs to contact insurance companies for patient care authorizations.
Utilized InterQual Criteria for accurate status placement during hospital stays.
Performed daily in-house reviews by liaising with insurance representatives.
Engaged with Security Blue and other insurers to facilitate authorizations.
Managed prior authorization requests and benefit eligibility reviews effectively.
Coordinated appeal calls to address and overturn denials.
Transitioned from Member Services Representative to the Utilization Review department, showcasing adaptability and growth.
Experience
7-10 Years
Level
Management
Education
BSN
Associate Utilization Review Specialist Resume
Summary : As a dedicated Utilization Review Specialist with 10 years of experience, I expertly evaluate patient care to ensure compliance with insurance requirements. My strong analytical skills and in-depth knowledge of clinical criteria facilitate effective resource management, enhancing patient outcomes. I am passionate about collaboration with healthcare teams to drive efficiency and optimize care delivery.
Collaborated with insurance companies and clinical teams to assess the appropriateness and level of care for complex cases.
Communicated significant findings and potential risk improvement issues promptly to the UR Manager and VP of Quality Assurance.
Maintained ongoing communication with the clinical team to ensure alignment on care plans.
Organized and secured UR documents, case files, and correspondence in compliance with confidentiality standards.
Coordinated daily client care management to ensure efficient service delivery.
Oversaw the delivery of care and services, ensuring staff supervision met quality standards.
Addressed client issues by facilitating communication between clinical staff and patients.
Experience
10+ Years
Level
Senior
Education
BSN
Utilization Review Specialist/Analyst Resume
Summary : Leveraging 10 years of extensive experience in utilization review, I specialize in critically analyzing patient care against insurance protocols. My strong background in clinical criteria application ensures optimal resource allocation and enhances patient outcomes. I am dedicated to fostering collaboration among healthcare professionals to streamline processes and improve service delivery.
Skills : Medical Terminology, Ethical Standards, Utilization Review, Multitasking Ability
Description :
Verified patient eligibility and benefits, conducting retro reviews for insurance compliance.
Prepare detailed reports on utilization trends and patterns.
Compiled and presented utilization review data to the Performance Improvement department.
Collaborated with billing and credentialing teams to optimize operations.
Communicate findings to medical staff and management effectively.
Maintained knowledge of intake processes and admission criteria to ensure compliance.
Facilitated communication between insurance providers and healthcare professionals.
Experience
10+ Years
Level
Senior
Education
BSN
Utilization Review Specialist Resume
Summary : Bringing a decade of specialized experience in utilization review, I focus on evaluating patient care for compliance with insurance standards. My strong analytical abilities enhance resource management and improve patient outcomes while fostering collaboration with healthcare teams to streamline processes and drive efficiencies.
Skills : Health Policy, Electronic Health Records, Coding Knowledge, Patient Care Standards, Performance Improvement
Description :
Support quality improvement initiatives through data analysis.
Collaborated with healthcare providers to develop treatment plans, discharge strategies, and ongoing care.
Drafted notification letters to initiate and manage appeals processes effectively.
Interpreted and communicated health care plan benefits and policies to stakeholders.
Facilitated live telephonic reviews with physicians and payor representatives to ensure clarity and compliance.
Coordinated with billing departments to ensure accurate payment processes from payors.
Led training sessions on Service Excellence to enhance employee performance and patient satisfaction.
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