Utilization Review Nurse Resume Sample
Kamille Stroman
4295 Robert Pine,
San Francisco,
CA
+1 (555) 928 7216
Work Experience
Associate Utilization Review Nurse, LPN
04/2018
-
PRESENT
Dallas, TX
- Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications
- Current active unrestricted license or certification to practice as a health professional within the scope of licensure in the State of TN required
- Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistentwith the member's eligibility, benefits and contract
- Applies clinical knowledge to work with facilities and providers for care-coordination
- Current active unrestricted license or certification to practice as a health professional within the scope of licensure in the State of VA or TN required
- Plans, directs, assigns, and evaluates the work of subordinates engaged in utilization review activities
- Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely utilization review system
- Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures
Utilization Review Nurse
01/2014
-
12/2017
Houston, TX
- Determines need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures
- Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement
- Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters
- Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information
- Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies
- Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies
- Attends Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance, as needed
- As a unit supervisor at the LAC-USC Medical Center
- Has immediate responsibility for organizing, assigning, and evaluating the work of at least seven Utilization Review Nurses
RN Utilization Review Nurse Bedford, Texas
02/2008
-
08/2013
Boston, MA
- Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards
- Participates in the formulation of and changes in utilization review procedures by assessing the effectiveness of the review system and providing information on the policies and procedures within the assigned medical areas
- Provides input for the in-service training program by identifying areas of deficiency in staff knowledge or experience
- Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for follow up on referrals
- Compiles data on number and status of reviews, physician advisor referrals, and type of physician advisor determinations
- Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system
- Participates in the work performed by subordinates
- Work retro Medicaid and prebill accounts efficiently and effectively obtaining authorizations for entire length of stay
- Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain of command
Education
University of Washington Tacoma
2003 - 2007
Bachelor's Degree in Nursing
Professional Skills
- Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines
- Strong organizational skills and able to proactively prioritize needs and effectively manage resources
- Experience with clinical applications/systems. Excellent analytic, research, and problem solving skills
- Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively
- Excellent communication, organization, and interpersonal skills. Car and valid driver’s license required
- PC Skills– demonstrates advanced proficiency in Microsoft Office applications and others data mining software
- Possesses strong mentoring skills
How to write Utilization Review Nurse Resume
Utilization Review Nurse role is responsible for interpersonal, computer, clinical, organization, basic, medical, facilitation, microsoft, analytical, leadership.
To write great resume for utilization review nurse job, your resume must include:
- Your contact information
- Work experience
- Education
- Skill listing
Contact Information For Utilization Review Nurse Resume
The section contact information is important in your utilization review nurse 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 Utilization Review Nurse Resume
The section work experience is an essential part of your utilization review nurse 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 utilization review nurse responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular utilization review nurse position you're applying to.
The work experience section should be the detailed summary of your latest 3 or 4 positions.
Representative Utilization Review Nurse resume experience can include:
- Strong computer skills including the ability to rapidly learn and use new applications
- Strong experience in chart review and discharge planning, ER and ICU experience
- Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
- Strong experience in chart review, discharge planning, Med Surg and ICU
- Strong experience in chart review, discharge planning, Med Surge and ICU
- Computer skills and typing expertise
Education on an Utilization Review Nurse Resume
Make sure to make education a priority on your utilization review nurse resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your utilization review nurse 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 Utilization Review Nurse Resume
When listing skills on your utilization review nurse 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 utilization review nurse skills:
- Excellent time management and problem solving-skills
- Demonstrated knowledge of pathophysiology with application of critical thinking skills
- Three years prior nursing experience in a hospital required with previous utilization review experience required
- Excellent analytic, research, and problem solving skills
- Strong organization skills, self-directed, flexible, able to adapt to rapidly changing regulatory requirements
- Solid analytical, assessment and documentation skills
List of Typical Experience For an Utilization Review Nurse Resume
1
Experience For Utilization Review Nurse Auditor Resume
- Proficient in MS word and excel applications. Previous experience working in an electronic medical record system
- Demonstrates excellence in communications to ensure customer satisfaction and retention
- Utilizes nationally recognized evidenced based guidelines to make medical necessity decisions
- Completing concurrent reviews for caseload to extend clients’ length of stay
- Participates in coordinating on-going education for Case Management staff regarding government and payor regulatory and outcomes
- Work assigned accounts in eRequest to resolve outstanding issues
- Report insurance denial trends identified during daily operational assignments
- Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc
2
Experience For RN Utilization Review Nurse Bedford, Texas Resume
- Participate in education and training as needed
- Serves as the primary contact for all payors regarding utilization review and management issues
- Assess the needs for a Medicare IM, delivers admission notice if not already done so by admitting
- Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial
- Contacts the attending physician to notify him/her of all decisions to issue a notice of non-coverage for all payers
- Maintains productivity and meets all UR performance standards according to department policies and procedures
- Attends education sessions each year for internal and external customers regarding utilization management
- Graduate of an accredited practical/vocational or professional nursing program
3
Experience For Utilization Review Nurse Supervisor Resume
- Handles complex, high acuity cases, and/or account sensitive cases involving largest reserves
- Current/active Nursing License - needs to be licensed in Georgia and Alabama- strictly telephonic
- Provide assistance to physicians and hospital staff with discharge planning to expedite hospital discharge
- Support orientation program for UR staff by acting as primary mentor for review nurse and physician reviewers
- Conducts service connection reviews using Quadramed and also assists with clinical reviews as directed by the CBO: i.e., The Combat Vet Project
- Responsible/accountable for professional development and maintaining licensure
- Function as subject matter expert for Wyoming Disability Determination reviews as well as complete additional utilization management specialty reviews
- Perform accurate and timely documentation of all review activities based on policy and procedure
4
Experience For Telephonic Utilization Review Nurse Onsite Resume
- Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed
- Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives
- Establish and maintain relationships with all customers
- Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
- Performs concurrent payor reviews for medical appropriateness for patients placed in outpatient observation or in an inpatient setting according to payor guidelines, rules and regulations
- Contacts the scheduling provider to get the correct status order for the scheduled procedure and/or secure documentation to support an ordered status or level of care
- Ensures inpatient vs. outpatient scheduling criteria is met in accordance with the payor and CMS requirements (inpatient only procedures)
- Establishes and maintains professional, collaborative working relationships with the Business Office Registration Department, Revenue Cycle Department and other key departments to facilitate processes to ensure timely and appropriate reimbursement for services provided
5
Experience For Utilization Review Nurse LPN Resume
- Initiates and coordinates the payor appeal process for all concurrent denials including arranging a scheduled time for the attending physician and payor Medical Director to discuss the clinical situation
- Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to utilization management
- Conducts retrospective medical appropriateness review as identified by internal and external audit and/or payor denials
- Meets Initial Clinical Review URAC Standards below
- Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third party information
- Appropriately uses Interqual criteria for leveling of care
- Completes CERME assessment, daily
- Ensures appropriate physician admission orders and level of care documentation by the physician
- Monitors physician compliance with the CMS 2 midnight rule
6
Experience For Utilization Review Nurse RN Resume
- Conducts concurrent admission and continued stay reviews based on appropriate utilization criteria, established standards, procedures and policies
- Documents authorization numbers, days approved data, and denial data as outlined in the departmental policy and procedures
- On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient’s physician to resolve the issue
- Proactively follows and intervenes on open cases to include concurrent appeals of denials
- Educates staff and physicians about managed care principles, observation status, reimbursement rules and range of patient care setting beyond observation, intensive care and acute hospitals
- Delivers second IM notice to Medicare recipients if appropriate, facilitating appeal if needed
7
Experience For Network Utilization Review Nurse Resume
- Works collaboratively with all Revenue Cycle departments to ensure accurate, timely communication regarding changes in patient status information
- Attends required education to maintain competency with CERME and other UR systems
- Collaborates with members of the multidisciplinary team to facilitate the case management and care coordination processes for the assigned caseload
- Consults with medical staff as needed to facilitate accurate documentation and to assure an appropriate timely discharge. Monitors and ensures physician compliance with the CMS 2 midnight rule
- Monitors patient progress and plan of care with the aid of internal and external utilization guidelines
- Contributes in a positive manner to the development of the UR department
- Communicates information in a clear and timely manner
- Participates in quality improvement and evaluation processes related to the CM practice
- Participates in the development of procedures, roles, systems and structures related to the UR practice
8
Experience For Pre-certification / Utilization Review Nurse Resume
- Interacts with patients, families, colleagues and external contacts with respect, sensitivity and attentiveness to promote teamwork and cooperation
- Adheres to UR department specific and organizational policies and standards such as TJC, Dept of Health, etc
- UR’s are on site and available seven days a week
- Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
- Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications
- A current, valid Michigan license to practice as a Registered Nurse without any conditions, limitations or restrictions
9
Experience For Associate Utilization Review Nurse, LPN Resume
- Applies worker’s compensation regulations, state laws and guidelines to case management activity in assigned territories
- Coordinates level of service justification directly with physician and communicates directly with third party payer to obtain approval
- Interact with social worker, community agencies to identify alternate delivery of services
- Reviews and/or coordinates requests for authorization of specialty services with external consultants, and Physician Advisors; Uses his/her own discretion in determining if submitted medical information needs a consultant’s review
- Educates external providers about HPHC’s utilization management guidelines for specialty services
10
Experience For Licensed Utilization Review Nurse Resume
- Licensed Practical Nurse (LPN) with current state license
- Communicating with the insurance department if a client does not have coverage or there are limitations on client’s policy that becomes available as case is opened with insurance company
- Working with clinical and client care team to communicate insurance case manager’s request for specific treatment, follow ups, and individualized care
- Participates in Contracting and Provider Relations activities as necessaryto develop and maintain provider networks. Identify and report when provider’s gaps in contracts are identified
- Refers all cases that are denied by the payor to the Concurrent Appeal URN or Physician Advisor
List of Typical Skills For an Utilization Review Nurse Resume
1
Skills For Utilization Review Nurse Auditor Resume
- Excellent verbal and written communication, organization and interpersonal skills
- Excellent communication (both written and verbal), organization and interpersonal skills
- Basic computer skills including word processing and spread sheets
- Nursing experience with one (1) year experience in Utilization Management
- Experience in acute long-term care, acute rehabilitation or skilled nursing facilities
- One year of care management, utilization management experience, clinical documentation or clinical auditing experience
- Utilization Review experience at a Managed Care plan or Provider Organization; 5+ years of Healthcare experience
- Develop leadership skills and to serve as a role model for clinical staff
- Demonstrates effective communication with adolescents, adults and older adults
2
Skills For RN Utilization Review Nurse Bedford, Texas Resume
- Documented experience in collecting, compiling, and performing preliminary analysis of data
- Experience with assisting with Discharge and Transition of Care Planning
- Documented experience assessing and interpreting clinical information from client records
- Documented experience consulting with physicians and other health team members regarding plan of care
- Recent clinical nursing experience in an acute-care hospital setting and/or payer case management
- Reviews and conducting special eligibility validation reviews including SC, Agent Orange, Combat Vet, etc
- Previous experience in an Acute Care, Hospital and/or Clinical setting
- Knowledge and experience in diverse Patient Care settings, including Inpatient Care
- Clinical experience in acute setting
3
Skills For Utilization Review Nurse Supervisor Resume
- Clinical experience in acute setting
- Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center
- Documented experience collaborating with various disciplines and/or areas within an organization
- Documented experience communicating information with outside entities, patients/families/assigned representatives, and/or staff
- Documented experience reviewing client medical records/charts
- Documented experience communicating information with outside agencies
- Documented experience discussing information with patients, families and/or assigned representatives
- Knowledge of CPT, ICD-10, and/or HCPC codes or coding experience
- Utilization Review experience
4
Skills For Telephonic Utilization Review Nurse Onsite Resume
- Previous Appeals / Denials experience
- Utilization Review experience
- Attention to detail with ability to prioritize, problem solve and multi-task
- Establish priorities, meet deadlines and maintain productivity standards in the management of the work assignment
- Perform utilization reviews to ensure that members receive necessary medical care in a timely and cost-effective manner
5
Skills For Utilization Review Nurse LPN Resume
- 6+ months of Concurrent / Utilization Review experience
- Demonstrate appropriate network utilization in accordance with regulatory requirements
- Proficient in computer technology and experience with Microsoft Office product Excel, Outlook, Word, Skype, etc
- Experience with clinical applications/systems
- Utilization Review experience for at least 1 year
- Acute care clinical experience
- Ensure full collection of clinical information prior to rendering a decision including contacting hospital providers for additional information as necessary
- Arrange alternative care services and maintain communication with acute long term care, acute rehabilitation or skilled nursing facilities
6
Skills For Utilization Review Nurse RN Resume
- Reports issues and system barriers to efficient and effective discharge planning to department leadership
- Lifting 50 lbs. (maximum) with frequent lifting and/or carrying of objects weighing up to 25 lbs
- Customer Orientation– establishes and maintains long term customer relationships, building trust and respect by consistently meeting and exceeding expectations
- Participate in company meetings, training activities and continuing education requirements
- Exp working in utilization mngt department (UR, UM, Discharge Planning, CM, Retrospective Review, Concurrent Review)
7
Skills For Network Utilization Review Nurse Resume
- Two (2) years Utilization Management and/or Hospital discharge planning in the acute care setting within the past four (4) years
- Conduct reviews using clinical assessment and established screening criteria
- Coordinates activities with other medical managmeent departments as needed, including making referrals to Case Managment and Behavioral Health
- Clinical practice in an acute care setting
- Quickly analyze and interpret data and write reports using standard medical terminology
- 1500 Spring Garden St
8
Skills For Pre-certification / Utilization Review Nurse Resume
- Assist in developing medical policies and procedures that directly impact member utilization of benefits
- 1000 S. Sterling Street
- DCS policies, procedures, and current State Federal and local laws governing AHCCCS/Medicaid health plan operations and requirements
- Proficient in using MS Word, MS Excel, and MS Outlook
- Background working with Medicare and Medicaid population
- BA/BS and nursing diploma. Current employees grandfathered (5/14)
9
Skills For Associate Utilization Review Nurse, LPN Resume
- Current, unrestricted RN license in the state of Wyoming
- Successful work history in a clinical setting and/or health insurance environment
- Accurately and completely documents in file using standard documentation format(s)
- Coordinate discharge planning to create member’s post-inpatient plan
- Evaluate the need for case management and transition of care services following inpatient stay
10
Skills For Licensed Utilization Review Nurse Resume
- Coordinate transportation with contracted vendors following inpatient stay
- Facilitate member’s transfers within contract facilities for ongoing inpatient stays
- Escalate cases not meeting criteria to Division PA
- Communicate with physicians regarding patient status, level of care. Medical necessity, utilization of resources, and denials
- Communicate lack of medical necessity and/or responder criteria being met to the facility Case Manager
- Ensure the member is at the appropriate level of care, in the appropriate setting, at the appropriate time through utilization review
List of Typical Responsibilities For an Utilization Review Nurse Resume
1
Responsibilities For Utilization Review Nurse Auditor Resume
- Documented skill in effective communication skills and professional behaviors that promote cooperation and teamwork
- Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software)
- Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software) required
- Three to five years clinical experience in a health care environment, with supervisory experience; Managed care experience desired
- Communicates effectively with other health care providers, patients, families, other hospital personnel and visitors
- Position requires candidates with determined and assertive communication skills
2
Responsibilities For RN Utilization Review Nurse Bedford, Texas Resume
- Behavioral health experience strongly desired
- Facilitates cost effective and quality patient care by effective communication with physicians, providers and members
- Solid understanding of Peer Review Organization criteria and standards, purpose and requirements needed; working knowledge of DRG payment system helpful
- Clinical nursing experience on an orthopedic/neurology nursing unit
- Ensures authorized services are performed in the most cost effective appropriate setting
3
Responsibilities For Utilization Review Nurse Supervisor Resume
- Educate providers about inpatient and outpatient cost-effectiveness, alternative placement and quality management
- Proven ability to work independently, with attention to detail and accuracy
- Evaluates effectiveness of care and facilitates coordination of care toward specific outcomes criteria
- Worker’s compensation or Occupational Medicine or Rehab experience desirable
- Experience in managed care, case managementd required
- HMO or managed care experience
- Current/valid State of Florida Registered Nurse licensure
4
Responsibilities For Telephonic Utilization Review Nurse Onsite Resume
- Case Management experience in an acute care setting
- Experience in a leadership role such as a manager, charge nurse, team leader, etc
- Acute care LPN experience
- Initiates the payor appeal process for all concurrent denials following the department guidelines for documentation and escalation
- Perform admission reviews, on in scope populations, utilizing InterQual within 24 hours of admission
- Professional conduct in all situations including clinical department meetings is required
- Documents clinical appropriateness reviews and care management activities in managed care operating systems
- Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs
5
Responsibilities For Utilization Review Nurse LPN Resume
- Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers.
- Understand and investigate billing issues, claims and other plan benefit information.
- Assist with monitoring, inquiries, and audit activities as needed
- Provides insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications
- Work rotating weekends and holidays
- Provide care coordination of members who are transitioning from one level of care to another
6
Responsibilities For Utilization Review Nurse RN Resume
- Participates in process performance improvement activities related to utilization management
- LVN with current state licensure
- Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan
- Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members
- Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. Manages own caseload and coordinates all assigned cases
7
Responsibilities For Network Utilization Review Nurse Resume
- Acts as a resource to others
- Active and unrestricted RN or LVN license in state of New Jersey
- Collaborates with the Case Manager, Social Worker, attending physician, and other healthcare team members to ensure medical appropriateness criteria, to develop an action plan to avert reductions in care or denials and to obtain all payor information that influence discharge planning activities
- Refers all cases that are denied by the payor to the Concurrent Appeal Nurse or Physician Advisor
- Serves as an educational resource for other Case Management staff, other internal departments, physicians, nursing staff and others concerning utilization management strategies essential in meeting the organization's quality, utilization, financial and customer satisfaction objectives
- Validate the patient’s status is correct (Inpatient vs Outpatient) based on physician’s order, take action to correct status if incorrect or no order is present. Document actions
8
Responsibilities For Pre-certification / Utilization Review Nurse Resume
- Perform initial admission clinical summary reviews within 24 hours or per payor contract on payors with an authorization process
- Perform continued stay clinical summary reviews as per payor contract on payors with an authorization process
- Review and manage concurrent denials per FWD Centralized Utilization Review policy
- Documentation to take place, per HCA and FWD guidelines, in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module
- Registered Nurse, licensed in Massachusetts
- Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
- Monitor quality of care and collect and analyze utilization data
- Serve as a resource and liaison between the health plan, behavioral providers, facilities, member and families
- Provide and review member intakes and initial evaluations
9
Responsibilities For Associate Utilization Review Nurse, LPN Resume
- Comply with performance measures in regards to denials, higher level of care admission certifications and concurrent review timeliness
- Develop and maintain collaborative relationships with providers and educate on levels of care
- Interact with physicians, social workers, providers, case managers, and internal staff to develop discharge plans and oversee their implementation
- Authorize and/or review utilization of mental health and substance abuse services provided in inpatient and intermediate care settings. Assure appropriate levels of care and medical necessity in a manner that supports the recovery process
- Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for Medical Bill Reviews, TX Plans, IMEs, Peer Review reports, correspondences, addendums and/or supplemental reviews
- Utilize evidence-based guidelines (Interqual) and collaborates with hospital case managers, social workers, Primary Care Physicians, attending physicians, internal team and medical directors on a daily basis
- Manage all transitions of care related to a hospital stay through patient interviews, effective planning, and collaboration with facility personnel and client teams to prevent unplanned transitions and re-admissions through proven interventions
10
Responsibilities For Licensed Utilization Review Nurse Resume
- Knowledgeable about member benefits and assists member to maximize their individual benefit plan
- Facilitate authorizations for post-acute care services or medications
- Review cases for quality of care concerns
- Documents authorizations and case management activities in software applications
- Assumes leadership role in POD/IPA related meetings and shares knowledge and information
- Participates in process improvement activities and all STAR-related initiatives
- Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%)
- Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%)
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