Rn-utilization Review Resume Sample
Ofelia Daniel
386 Bradly Ramp,
San Francisco,
CA
+1 (555) 848 0460
Work Experience
Rn-utilization Review Specialist
04/2018
-
PRESENT
Philadelphia, PA
- Document note to support Inpatient admission
- Ensure the patient’s status is correct (Inpatient vs Outpatient)
- Communicate medical necessity and responder criteria to the facility Case Manager
- Review the Certification / Authorization report daily to determine deficiencies
- Documentation to take place in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module
- Clear and current CA RN license
- Wpm and 10 key by touch required
- Applies Milliman Careguidelines Criteria for appropriate status determination
Utilization Review RN
06/2013
-
01/2018
Los Angeles, CA
- Ensures timely communication with Case Management staff for all concurrent status changes
- Documents in the Medical Record Utilization Management forms accurately to reflect the appropriate admission criteria and appropriate status along with any communications
- Reviews the records on admission for status orders present addressing Center for Medicare Services rules and guidelines around admission status
- Monitors insurance coverage for patients in the STAR admitting/financial system and communicates any updates to the Verification Department
- Provides clinical information as request from the insurance payer via telephone or fax in a timely manner to prevent technical denials
- Enters authorization, approvals and denials into the STAR systems and communicates pertinent changes to Case Management
- Reviews denial letters/faxes received in Care Coordination Department and direct to Conifer Appeal Department for appeal. Documents in the STAR system
- Collaborates in monitoring and addressing observation outliers and status discrepancies with Medical Records Department and Admitting Department
Optum Field Based Utilization Review Rn-maricopa County
06/2009
-
03/2013
New York, NY
- Collaborates with the Recovery Audit Contractor (RAC) Coordinator and Conifer for Medicare/Medicaid RAC Denials management
- Perform initial, concurrent, discharge and retrospective reviews on all patients
- Review current charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients).Communicate directly with insurance companies and/or payor to obtain admission and continued stay certification or recertification
- Facilitate peer to peer appeal for concurrent denials
- Fax reviews per policy and as needed to stay current on certified days
- Collaborate with Care Coordination Medical Director on patients not meeting criteria and informs Clinical Resource Manager/Director as needed
- Assign a working diagnosis related groups (DRGs) on all patients
Education
Strayer University - Center City Campus
2004 - 2008
Bachelor's Degree in Nursing
Professional Skills
- Demonstrates analytical and critical thinking abilities with pro-active decision making and negotiations skills
- Basic computer and typing skills are required
- Proficient computer skills, including knowledge of Microsoft office suite
- Working knowledge of skilled nursing facilities & long term acute care facilities
- Work effectively with a variety of customers including physicians, office staff and members
- Five (5) years clinical nursing experience
- Experience in an acute care setting
How to write Rn-utilization Review Resume
Rn-utilization Review role is responsible for software, compliance, education, finance, regulatory, microsoft, travel, training, database, printing.
To write great resume for rn-utilization review job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Rn-utilization Review Resume
The section contact information is important in your rn-utilization review 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 Rn-utilization Review Resume
The section work experience is an essential part of your rn-utilization review 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 rn-utilization review responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular rn-utilization review position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Rn-utilization Review resume experience can include:
- Interacts effectively and professionally with physicians and hospital staff
- Using the medical software criteria, establish the need for inpatient, continued stay and length of stay
- Ensuring regulatory compliance requirements are met
- Communicate with attending physician regarding patients who do not meet criteria to identify additional documentation needs or potential status change
- Responsible for timely and appropriate denial letters that meet standards, coordinating with other team members, printing and distribution of letters
- Direct the delivery of care to the most appropriate setting, while maintaining quality
Education on a Rn-utilization Review Resume
Make sure to make education a priority on your rn-utilization review resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your rn-utilization review 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 Rn-utilization Review Resume
When listing skills on your rn-utilization review 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 rn-utilization review skills:
- Participate in weekly interdisciplinary team meeting at the skilled nursing facility
- Determine medical appropriateness of ongoing skilled nursing needs and benefit determination
- Previous experience in utilization management, discharge planning and/or case management
- Utilization Review experience in a managed care, home health or hospital setting
- Previous experience in discharge planning
- Travel to skilled nursing facilities throughout the Maricopa County, AZ
List of Typical Experience For a Rn-utilization Review Resume
1
Experience For Utilization Review RN Resume
- Direct patient care experience as a registered nurse
- Communicate problems or trends with insurance companies to Clinical Resource Manager/Director
- Perform chart analysis on quality surveillance and special studies as requested
- Location/Facility – Temple, Health Plan
- Location/Facility – Baylor, Scott & White Health - Dallas, TX (with the opportunity to work remote after a 6-8 week orientation)
- Autonomous and self-starter in work activities
- Provides timely and continual coverage of assigned work area in order to ensure all accounts are completed. Meets attendance requirements, and is flexible during periods of short staffing, and/or high volume
2
Experience For Optum Field Based Utilization Review Rn-maricopa County Resume
- Oversees and coordinates compliance to federally mandated and third party payer utilization management rules and regulations
- Knowledge of MS Office products such as MS Word and MS Outlook
- Health Plan Required
- Assure the RN Care Coordinator assigned to the patient is aware of the self-pay status of patients and make necessary referrals to financial counselors and/or hospital’s contracted financial counseling agencies, members of the healthcare team regarding target length of stay (LOS), acute care criteria, pay requirements, resource utilization, and care options to meet patient needs
- Familiarizes self with authorization requirements for assigned payers, based on payer matrix. Assist in ensuring proper patient status authorization, by reviewing patient admission status within the Cerner Care Manager system and matching with the correct authorization. Expedites communication with insurance contacts to assure timely authorization is received
- Works proactively to avoid inpatient denials, providing additional information and clarification to commercial contacts as appropriate, facilitating peer-to-peer reviews and/or concurrent appeals process when necessary in close collaboration with facility Case Mgmt. Obtains information from the insurance carrier regarding their concurrent/retrospective appeal process in the event of claim denial
List of Typical Skills For a Rn-utilization Review Resume
1
Skills For Utilization Review RN Resume
- BA or Combination of Education and Experience
- Acute inpatient case management / utilization review experience
- Able to autonomously prioritize, plan, and handle multiple tasks/demands simultaneously
- Five (5) years of experience as an RN required
- Two (2) years of experience in a medical insurance environment required
- Nursing - Utilization Review Required or
2
Skills For Optum Field Based Utilization Review Rn-maricopa County Resume
- Contact attending physicians regarding treatment plans/plan of care and clarify medical need for inpatient stay or continued inpatient care
- Identify inpatient admissions no longer meeting criteria and refer care to plan Medical Directors for evaluation
- Perform early identification of hospitalized members to evaluate discharge planning needs
- Participate in the process of educating providers on managed care
- Nursing - Concurrent Review Required or
- Care Coordination - Discharge Planning Required or
- Communicate identified patients who do not meet criteria to Care Coordination for discharge planning
- Registered Nurse or Licensed Practical Nurse with PA state license
- Perform telephonic utilization management for inpatient admissions
3
Skills For Rn-utilization Review Specialist Resume
- Present cases to Medical Directors that do not meet established criteria and provide pertinent information regarding member’s medical condition and the potential home care needs
- Collaborate with hospital case management staff, physicians and families to determine alternative setting at times and provide support to facilitate discharge to the most appropriate setting
- Identify quality of care issues including delays in care
- Identify and refer cases for case management and disease management
- Maintain the integrity of the system information by timely, accurate data entry
- Work to build relations with all providers and provide exceptional customer service
- Report potential utilization issues or trends to designated supervisor and recommendations for improvement
- Specialty certification in Utilization Review within 12 months of hire
- Specialty/Department/Practice –Customer Care Division
4
Skills For Supervisor Utilization Management Review, RN Resume
- Specialty/Department/Practice – Utilization review
- O Immediate eligibility for health and welfare benefits
- Specialty/Department/Practice –Utilization Review
- Active RN license in VA without restrictions
- Specialty/Department/Practice – Utilization
- Active RN license in LA
- CCM or ACM certification
- Working knowledge of federal, state, and regulatory requirements in performance improvement, utilization management, resource management, hospital systems, accreditation, and licensure
- Knowledge of Case Management process and the Utilization Review process
5
Skills For RN, Utilization Review Resume
- Knowledge of Medical Necessity Criteria
- Knowledge of Medicare regulations as they relate to Inpatient, Observation and Outpatient services
- Certification in Case Management (CCM) or MCG Certification
- Competent in use of Microsoft Word, Excel, and Windows. Keyboarding skills and the ability to utilize computer equipment and software are required as is experience with other types of standard office equipment. 45wpm and 10 key by touch required
- The Manager or Utilization Management works under the direction of the Director Management to plan, organize, implement and evaluate the utilization management program at Florida Hospital Memorial Medical Center
- This includes Authorizations, Initial Reviews, Concurrent Reviews, Denials and Appeals
- Responsible for review of hospital medical necessity denials, and completes timely submission of all appeals for each level of appeal needed; documents all outcomes appropriately
- Responsible for RAC Readiness case review audits, and the tracking of outcomes involving RAC/MAC/MIC/PAC, Commercial Payers, Managed Care, etc. for Florida Hospital Memorial Medical Center
- Oversee points of entry access management and front-end denial management processes
6
Skills For Utilization Review Rn-bradley Resume
- Analyze and monitor metrics to identify trends for process or performance improvement that impact denial rates and reimbursement
- Works with the RN care managers, Patient Access, Compliance Nurse Manager Auditor, HIM Staff, CDI staff, Revenue Cycle Team, Care Management Services Physician Advisor (s), Chief Medical Officer and other Medical Staff for educational opportunities to prevent future denials
- Experienced in a supervisory role for utilization review or care management services, managed care services, discharge planning and transitional care planning within a hospital acute care or community –based care setting (s)
- Effective and professional presentation skills
- Prior experience as an RN Care Coordinator
- Two (2) years experience in a medical insurance environment required
- Clarifies information and answers prior authorization questions from medical offices and providers
7
Skills For RN Utilization Review PRN Resume
- Performs audit of prior authorization database to monitor timelines set by NCQA
- Strong Interqual knowledge
- Certification in care coordination or utilization review
- Current American Heart Association BLS for Health Care Providers required
- Healthcare - Acute Care Required or
- Ensures prior authorizations are entered into the UM Module for those services requiring prior authorization from the patient’s third-party payer. Enters approved hospital days into the UM Module when received by the patient’s payer
8
Skills For Utilization Review Rn-weekends Resume
- Participates in daily departmental planning meetings and meets with the clinical team to guide the patient’s discharge plan
- Predicts and plans for patient’s needs from admission through acute and sub-acute care and post-discharge, in collaboration with the patient’s third-party payer and providers
- Acts as a liaison with the RN Care Coordinators and Care Coordination Social Workers to facilitate the appropriate utilization of hospital resources and
- Timely discharge. Tracks and reports trends of inappropriate utilization of resources to the Utilization Review Manager
- Evaluates new admissions and continued stay for medical necessity using approved criteria through the utilization of the electronic medical record. Application of criteria for medical necessity determination and appropriateness of level of care
- Work closely with health partners, members and the interdisciplinary care team to facilitate appropriate discharge planning
- Assumes a collaborative role with the interdisciplinary team to make certain the appropriate level of care, patient status and resource utilization is reached
- Demonstrates knowledge of regulatory requirements, HCA ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations as it relates to the provision of Utilization Review (UR) services
9
Skills For RN Utilization Review Case Manager Resume
- Identifies patients with the potential for high risk complications and makes appropriate referrals to the Facility CM team acting as an advocate for the individual's healthcare needs
- Visit OptumCare Arizona- members in skilled nursing facilities and/or in long term acute care inpatient facilities
- Provide a complete continuum of quality care through close communication with members via in-person or telephonic interaction
- Perform utilization management, utilization review, or concurrent review (onsite or telephonic)
- Collaborate with the care team to meet patient-centric affordability goals and quality outcomes
- Reviews and approves prior authorization requests for medical necessity within NCQA timelines using the predetermined criteria provided by the different plans and UM Committee criteria
10
Skills For Acute Onsite Rn-utilization Review Resume
- Reviews correct CPT, HCPC, ICD-9 codes for each referral
- Prepares frequent emergency room usage information for UM management
- Performs audits of various medical records and documentation and implementation of criteria of various staff
- Communicates with all parties (i.e., staff, physicians, payers, etc.) in a helpful and courteous manner while extending exemplary professionalism. Anticipates and responds to inquiries and needs in an assertive, yet courteous manner. Demonstrates positive interdepartmental communication and cooperation
- Interacts with physicians, physician office personnel, and/or case management departments on an as-needed basis to ensure resolution of pending denials, which have been referred to the physician for peer-to-peer review with the Medical Director of the insurance carrier
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