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 : Motivated, personable nursing health care director professional with multiple college degrees and a successful 10-year track record of providing quality patient care.
Skills : Technical Skills, Analysis.
Description :
Offered immunizations, shots, general exams, health education materials, and over the counter medication as needed.
Assisted in company health/wellness examination programs.
Orderedpatient appropriate DME equipment as needed Arrange home health, IV antibiotics and Wound vacs as needed.
Assisted employee health nurse with duties as assigned as needed.
Responsible for all hospital readmission assessments of patients readmitted with thin 3o days.
Helped the patient/families navigate through possible barriers to care.
Ensured the patient is able to get medical access and referral resources in an efficient and expedited manner.
Summary : To obtain a challenging position in the medical field where can utilize skills and also be a learning experience at a great company.
Skills : Problem Solving Skills, Analytical Skills.
Description :
Ensured compliance and accuracy while identifying actions in need of reviews.
Completed admissions reviews, stay reviews, and observations reviews.
Identified appropriateness of the level of care as well as issues and/or delays with treatments and services.
Coordinated inpatient reviews of Medical-Surgical, Intensive Care and Behavioral Health with InterQual(TM) guidelines.
Trained new Utilization Review staff on InterQual(TM) standards.
Developed a template requiring all providers, social workers, UR and charge nurses on the assigned unit to sign.
Generated utilization management reports and determined performance measures not being met.
Collaborated daily with providers, nursing staff, and Physician Utilization Management Advisors.
Experience
7-10 Years
Level
Management
Education
Associate
Utilization Review Specialist I Resume
Objective : Passionate, dedicated and insightful professional seeking a challenging and rewarding position in the Social Work field as a Counselor or Therapist working with culturally.
Skills : Case Management, Utilization Review experience.
Description :
Communicated information received to appropriate staff in a timely and efficient manner.
Worked with the clinical/medical team to ensure, that the care manager's questions and concerns are documented in the clinical record.
Experience to assist admissions department with placement criteria.
Negotiated and built a rapport with payers regarding patient treatment needs.
Managed denials and conducted doctor reviews to maintain the highest level of care.
Performed all duties in a timely manner which may require availability on-site or via cell phone.
Identified and reported variations in the quality and appropriateness of care using ASAM and insurance medical necessity criteria.
Experience
2-5 Years
Level
Junior
Education
Certification
Utilization Review Specialist III Resume
Summary : Under general supervision, reviews client health records to ensure proper utilization of treatment resources.
Skills : Interpersonal Skills, Answering Phones.
Description :
Managed incoming calls or incoming post services claims work.
Determined the contract and benefit eligibility; provides authorization for inpatient admission, outpatient precertification, prior authorization.
Referred cases requiring clinical review to a Nurse reviewer.
Responsible for the identification and data entry of referral requests into the UM system in accordance with the plan certificate.
Responded to telephone and written inquiries from clients, providers and in-house departments.
Authorized the initial set of sessions to the provider.
Checked benefits for facility-based treatment Develops and maintains positive customer relations and coordinates with various functions.
Experience
10+ Years
Level
Senior
Education
BS
Utilization Review Specialist II Resume
Headline : Utilization Review Specialist is responsible for reviewing and processing utilization data within the system. This includes general data entry, reports, and analysis.
Skills : Data Entry, Medical Terminology, Customer Service.
Description :
Reviewed Specialist Screened all medical documentation and make decisions.
Provided information to determine the most efficient and appropriate method of transport or most appropriate medical provider.
Audited whether provider billed for previously canceled trips and/or was paid for trips that did not occur.
Reviewed ineligible rider reports and medical necessity forms.
Assisted with standing order recertification.
Assisted with booking enrollee's out of state trip request by communicating with physicians and caseworkers.
Handed enrollee's gas, hotel and flight Reimbursements.
Trained new employees on how to understand and read the medical necessity form.
Experience
5-7 Years
Level
Executive
Education
Associate Of Science
Utilization Review Specialist/Executive Resume
Headline : Customer Service Professional with experience in the healthcare industry and a specialty in credentialing information for a variety of medical professionals.
Skills : Pharmacy, Organizing.
Description :
Authorized cases according to standard approval process documents.
Documented clinical/non-clinical information to progress the utilization or case management process.
Sent letters to members and providers as required. Kept spreadsheet of all cases coming in and what RN handled in the case.
Maintained all regulatory timelines to support compliance with state and federal regulations.
Obtained authorizations from insurance companies for acute inpatient mental health hospitalizations.
Concurrent reviewed for continued authorizations and chart audits.
Reviewed on pts.status to insurance companies to get authorization for continued status on pts.condition.
Experience
5-7 Years
Level
Executive
Education
Diploma
Utilization Review Specialist III Resume
Summary : Diversified experience in the Health Care Arena. Experienced in Psychiatric and Medical-Surgical Case Management.
Skills : Utilization Review, Discharge Planning.
Description :
Interacted daily with team members, intake assessments assisted clients with financial resources.
Managed financial constraints, wrote appeals for reimbursement and assisted in the quality assurance process.
Instrumented the hospital receiving Designated Status with Blue Cross.
Resulted in time and cost savings to the Psychiatric Department.
Co-facilitated educational series for the nursing department known as psychiatric Grand Rounds.
Solved complex financial billing situations resulted in money returned to clients and higher level of customer satisfaction.
Assisted risk management to prevent and reduce litigation for the entire hospital.
Experience
10+ Years
Level
Senior
Education
Bachelor
Lead Utilization Review Specialist Resume
Summary : Responsible for Demonstrating effective verbal and written communication skills with internal and external customers, i.e., insurance companies, case managers, home care agencies, physicians, nursing staff and ancillary personnel.
Skills : Problem Solving Skills, Technical Skills.
Description :
Assisted RN's on the hospital unit by contacting various insurance companies.
Obtained authorizations for a current hospital stay using InterQual Criteria for correct status placement of patients.
Contacted insurance companies when needed for daily inhouse reviews.
Communicated with Security Blue and some other insurances.
Required for authorization of MA admissions. Data Entry Prior Authorization Benefit Eligibility Concurrent Review.
Scheduled appeal calls to overturn the denial.
Hired as Member Services Rep.Promoted to UR dept.
Experience
7-10 Years
Level
Management
Education
LPN In Nursing
Associate Utilization Review Specialist Resume
Summary : To obtain a challenging, rewarding position in a health care facility that will enable to use strong passion for helping others, customer service skills, educational background.
Skills : Medical Terminology, Medical Insurance, Excellent Interpersonal Skills.
Description :
Responsible for consulted with insurance companies and clinical teams to evaluate appropriateness and level of care for complex or difficult cases.
Communicated significant findings, including potential risk improvement issues to the UR Manager or VP of Quality Assurance as indicated in a timely manner.
Maintained regular communication with the clinical team.
Responsible for maintained UR documents, case files, and correspondence in an organized, confidential and secure manner.
Responsible for ensuring that Client care is coordinated and managed appropriately daily.
Ensured that care and services are delivered appropriately and for the supervision of personnel.
Communicated with the clinical staff when issues arise with their clients.
Experience
10+ Years
Level
Senior
Education
Bachelor's
Utilization Review Specialist/Analyst Resume
Summary : To obtain employment where can use skills as a Licensed Practical Nurse to the best of ability to benefit employer and support the nursing staff.
Skills : Management, Problem Solving Skills.
Description :
Verified eligibility and benefits for patients. Retro reviews requested by insurance companies.
All pre-certifications and concurrent reviews for all managed care.
Compiled all information for the UR department and report this to the PI department with the corporate office.
Worked closely with our billing department as well as the credentialing officer for at corporate Accomplishments.
Established new procedures for our UR department regarding changes to the Medicaid changes.
Stayed knowledgable of our intake procedures and admission criteria Skills Used LPN.
Communicated with our insurance company's and also when communicating with all Doctors.
Experience
10+ Years
Level
Senior
Education
Nursing
Utilization Review Specialist Resume
Summary : To utilize skills in direct clinical care, case management services and business administration to promote community and organizational development.
Skills : Electronic Medical Records System, Data Entry.
Description :
Directed and performed concurrent and retrospective reviews for inpatient, partial and intensive outpatient levels of care.
Consulted with physicians, therapists and health care providers regarding treatment, discharge planning, and continuing care.
Prepared notification letters to initiate appeals processes.
Interpreted health care plan benefits, policies and procedures for members, physicians, therapists, and hospital administrators.
Coordinated live telephonic reviews for physicians and payor representatives.
Coordinated with claims and billing departments to ensure proper payment of accounts from payors.
Facilitated Service Excellence training sessions for employees during orientation and annual requirements seminars.
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