Nurse Reviewer Resume Sample
Stephany Bayer
4299 Shyann Track,
Boston,
MA
+1 (555) 185 7087
Work Experience
NGS Nurse Reviewer Senior
02/2016
-
PRESENT
Phoenix, AZ
- Receives preauthorization requests from front-line intake
- Conducts initial medical necessity clinical screening
- Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
- Conducts initial medical necessity review of out of network preauthorization requests for services requested outside of the client health plan network
- Notifies ordering physician or rendering service provider office of the preauthorization determination decision
- Documents the results of the initial clinical review and determination in the precertification computer system
- Maintains confidentiality of patient and provider specific information
- Develops telephone service standards to meet departmental performance metrics
- Receives pre-authorization requests from front-line intake
Nurse Reviewer
10/2012
-
08/2015
Chicago, IL
- Conducts initial medical necessity review of out of network pre-authorization requests for services requested outside of the client health plan network
- Notifies ordering physician or rendering service provider office of the pre-authorization determination decision
- Documents the results of the initial clinical review and determination in the pre-certification computer system
- Monitor and evaluate patient’s plan of care and identify potential issues through telephonic outreach. Recommend appropriate interventions
- Receives requests for pre certification of procedures via telephone, fax, or Web
- Evaluates, identifies, and reports on quality of care issues
- Experience with medical record review of short stay inpatient acute care admissions
- Recent experience applying MCG for inpatient level of care determinations
Inpatient Nurse Reviewer
05/2010
-
08/2012
Dallas, TX
- Recent experience applying IQ for inpatient level of care determinations
- Experience with CMS clinical review guidelines for Medically Necessary inpatient admission
- Unrestricted NJ RN license required
- Performs clinical and medical reviews, data collection and database entry
- Assures that all work is completed within contractual deadlines and that all components of the completed review are present
- Delivers final product to the client per client specific contractual guidelines
- Performs retrospective chart review per contract specifications
- Evaluates, identifies, and reports on, quality of care issues
- Conduct on-site reviews and assessments of Member’s community long term care needs to determine medical necessity and clinical eligibility for Community Case Management and Continuous Skilled Nursing Services Determine and authorize services for Members in accordance with program guidelines and regulations
Education
Keiser University - Fort Lauderdale Campus
2006 - 2010
Bachelor's Degree in Nursing
Professional Skills
- Car and Valid Driver’s License, excellent telephonic problem solving, organizational, communication, and interpersonal skills
- Regularly contributes to the development of new concepts, techniques, and standards requiring varied interpersonal and technical skills
- Clinical experience; or any combination of education and experience, which would provide an equivalent background
- Assisting in preparation with Risk Adjustment Data Validations (RADV) audits
- Risk adjustment experience with in-dept knowledge of CPT coding, ICD 9 and 10 coding, and medical terminology
- Recent clinical nursing experience in an ambulatory or hospital setting
- Demonstrated proficiency in adapting/tailoring best practices/processes to business needs
How to write Nurse Reviewer Resume
Nurse Reviewer role is responsible for travel, government, training, database, auditing, security, compensation, reporting, research, insurance.
To write great resume for nurse reviewer job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Nurse Reviewer Resume
The section contact information is important in your nurse reviewer resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:
- First and last name
- Telephone number
Work Experience in Your Nurse Reviewer Resume
The section work experience is an essential part of your nurse reviewer resume. It’s the one thing the recruiter really cares about and pays the most attention to.
This section, however, is not just a list of your previous nurse reviewer responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular nurse reviewer position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Nurse Reviewer resume experience can include:
- Monitor timeliness of reviews of ensure timely effectiveness in order to meet applicable standards
- Monitor timeliness of reviews to ensure timely effectiveness in order to meet required CMS standards
- Data Analysis and Interview experience
- Five or more years of clinical experience as a registered nurse
- Valid Driver’s License (On-site only)
- Serving as main point of contact for coding questions and issues
Education on a Nurse Reviewer Resume
Make sure to make education a priority on your nurse reviewer resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your nurse reviewer experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.
Additional details to include:
- School you graduated from
- Major/ minor
- Year of graduation
- Location of school
These are the four additional pieces of information you should mention when listing your education on your resume.
Professional Skills in Nurse Reviewer Resume
When listing skills on your nurse reviewer resume, remember always to be honest about your level of ability. Include the Skills section after experience.
Present the most important skills in your resume, there's a list of typical nurse reviewer skills:
- Current medical/surgical and/or psychiatric nursing experience
- Licensed Practical Nurse with current license in the Commonwealth of Massachusetts and 6 years clinical nursing experience
- Recent work experience providing direct care or case management to adult patients with complex medical needs
- Experience in one of the following areas: Long-Term Care, Home Care, Rehab, Brain Injury, Mental Health, Substance Abuse and/or Disabilities
- Experience with utilization management, discharge planning, and electronic medical record systems
- Experience managing Medicaid claims operations
List of Typical Experience For a Nurse Reviewer Resume
1
Experience For UR Nurse Reviewer Resume
- Performing chart retrieval and medical record review to collect data for quality and reimbursement purposes
- Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate clinical eligibility
- Conduct on-site reviews and reassessments of applicant/participant/informal supports’ ability to assist with providing care when determining the medical necessity and clinical eligibility for assigned program and health care services
- Where applicable, determine and authorize services for applicants/participants in accordance with program guidelines and regulations
- RN with current licensure to practice in state of program operations
2
Experience For Inpatient Nurse Reviewer Resume
- Review documentation to insure that care meets insurance coverage criteria and Joint Commission requirements
- Identifies knowledge gaps and works with nurse manager as a resource for the team
- Consults with clinical staff to clarify data integrity issues and works with clinician to make appropriate corrections per organization policy
- Audit patient accounts at key intervals throughout the patient’s course of treatment and monitors charge activity at a patient level to avoid denials related to overutilization of services, lack of medical necessity or changes in insurance coverage throughout the course of treatment
- RN licensed in the state of Delaware
3
Experience For Nurse Reviewer, Utilization Resume
- Knowledge of Medicare regulations, Outpatient Services
- Use of statistics knowledge
- Perform medical necessity reviews for Medicare QIC Durable Medical Equipment (DME) cases assigned
- Review files to determine medical necessity of itmes at issue as well as determine coverage under Medicare
- Communicate the review findings in a clearly written report
4
Experience For Nurse Reviewer Specialty Resume
- Independently manage workflow; proficient in Microsoft Office software
- Make decisions with appropriate data
- Education: Registered Nurse or Licensed Practical Nurse
- Understands and complies with applicable URAC workers’ compensation utilization management standards
- Current, unrestricted RN, LPN, or LVN license required
- Term Life Insurance
List of Typical Skills For a Nurse Reviewer Resume
1
Skills For UR Nurse Reviewer Resume
- Registered Nurse with a current, valid unrestricted license in the state of California
- Previous utilization and/or quality management and/or call center experience is helpful
- Three or more years of medical surgical experience
- Determining correctness of physician diagnosis/documentation as it relates to risk
- Become a subject matter expert (SME) using job aides and learning tools
- Perform special projects including legal research, general medical research, or drafting proposal sections
- Verifies appropriate ICD and correct Date of Service (DOS) are captured: follows CMS regulations and authoritative guidelines for coding and billing
- Coordinate the development and maintenance of procedures for consistency of reviews and training of new personnel
- Identify data inconsistencies/missing information and collaborate with physician and clinical staff to assist with correction as needed
2
Skills For Inpatient Nurse Reviewer Resume
- Review other supporting clinical documentation to insure that record reflects overall patient condition/status
- Provide ICD coding based on clinical documentation
- Consults and educates staff regarding Medicare, Medicaid and Other Insurance coverage issues
- Research issues using federal law and Medicare regulations/coverage policies
- Proficiency with computer platforms and applications, particularly Microsoft Office
- Review cases and summarize the facts of each case and assess issues involved in the case to certify or non-certify requested treatments
- Review, organize and identify all medical records provided for CA workers comp cases
3
Skills For Nurse Reviewer, Utilization Resume
- Monitor timeliness of reviews to ensure applicable standards are met
- Primarily sedentary work in a general office environment- Ability to communicate and exchange information- Ability to comprehend and interpret documents and data
- Tax-advantaged health care and dependent flexible spending plans
- An array of Health, Dental and Vision Care Insurance plans
- 401(k) Employee Savings Plan with company match
- Health club reimbursement allowance
- Licensure reimbursement for medical professionals
4
Skills For Nurse Reviewer Specialty Resume
- Conducts initial medical necessity clinical screening and determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review
- Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network
- Mentors and coaches new employees in the nurse review process
- Follows-up as necessary to obtain additional clinical information as applicable
- Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics
- Work experience with at least 3 recent years providing direct service or case management to pediatric patients or young adults with special needs
- ICU, OR, PACU experience
- O Education: Registered Nurse or Licensed Practical Nurse and current RN/LPN license
- Qualified Mental Retardation Professional (QMRP) or Qualified Mental Health Professional (QMHP)
5
Skills For Quality / Safety Nurse Reviewer Resume
- Resilient, collaborative, self-motivated, flexible, innovative
- RN with current MA licensure to practice in state of program operations
- Travel statewide, specifically in the Western part of MA
- UMMS seeks a nurse who works autonomously and self-directed to conduct in-person clinical eligibility determinations for four (4) EOHHS/MassHealth Home and Community Based Service (HCBS)Waivers in Western and Central Massachusetts. The position allows the nurse to work remotely with travel to facilities to conduct assessments 3-4 times per week
- Prospective clinical review of outpatient advanced imaging procedures such as CT, MRI, Nuclear Cardiology and PET Scans
6
Skills For Disability Nurse Reviewer Resume
- RN with current licensure to practice in state of program operations (MA)
- Clinical review for cardiology and specialty pharmacology products and services
- Oncology Management programs leveraging AIM's proven specialty benefit platform to drive consistent and effective cancer care through services review along with management of close to 70 oncologic drugs
- Specialty Drugs programs to provide review for over 142 specialty drugs offering providers an automated drug review process through our provider friendly web portal
- Sleep Management, designed to align the diagnosis and treatment of sleep apnea against clinical guidelines, enhance member access to high value providers and ensure treatment compliance for the dispensing of supplies
- Plans implementation, training, and solution deployment
- Interprets applicable regulations and policies associated with case to determine recommendation
7
Skills For NGS Nurse Reviewer Senior Resume
- Use and maintain reliable internet service. Broadband/Cable internet is recommended with an 80 megabits download capability
- Work in multiple computer programs with dual screens
- Remote Workers are responsible to make the appropriate work arrangements that maintain separation between the employee’s private life and business activities
- An established and demonstrated safe and quiet home work environment (as defined by the Remote Worker PI Policy and the Remote Worker Privacy and Security Checklist
- Related work experience
- NICU experience required
- Detailed understanding of Medicaid policies and procedures at both Federal and State levels
8
Skills For Nurse Reviewer / Clinical Adjudicator Resume
- Use and maintain reliable internet service. Broadband/Cable internet is recommended with a 80 megabits download capability
- 12:00-22:30, weekend rotation and holiday rotation
- Conduct routine and ad-hoc evaluations and re-evaluations of Members’ services
- Evaluate and document the appropriateness of Members’ services and make modifications, as required
- Perform independent review of Administrative Law Judge determinations for inappropriate decisions or errors of law
- Process favorable, partially favorable and unfavorable appeals with correct decision information
- Knowledge of health regulations, guidelines and coverage issues
- Knowledge of statistical terminology and use of statistics
9
Skills For Nurse Reviewer Resume
- Perform independent review of favorable and partially favorable Administrative Law Judge determinations in accordance with the Part A, Part B, and DME Medicare regulations to determine if there are errors in the application of law or evidence
- Research issues using federal law, federal regulations and CMS policy
- Summarize policy legal issues to be submitted to the Medicare Appeals Council
- Work directly with federal government entities and contractors in regards to appeals and other special initiatives as requests from other government entities dictate
- Coordinate and assist in the development and maintenance of written procedures for consistency of reviews and training of new personnel
- Perform other special projects not related 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
- Review Prior Authorization requests, as assigned, and make clinically appropriate decisions and medical necessity determinations to adjudicate these requests, based on established procedural standards and MassHealth program rules, regulations and clinical guidelines
10
Skills For UR Nurse Reviewer Resume
- Comply with all established procedural standards and MassHealth program rules and regulations
- Contribute as an active member of a multi/inter-disciplinary team to assess, plan, organize, review and evaluate the care needs of members requiring health care services
- Contact providers, state agency offices, and other parties with knowledge of the member to obtain information and records needed to conduct a comprehensive clinical review of cases and final determinations
- Maintain assigned work list, meeting all deadlines
- At least 3 recent years providing home health care, direct service or case management
- Attend and participate in meetings, as required
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