Case Utilization Management Specialist Resume Example

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Jessica Claire
, , 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - - -

Highly adaptable Utilization Review Nurse dedicated to providing exceptional skills in the hospital or insurance case review environment. Smart with developed interpersonal and time management skills. Seeking challenging role in setting devoted to quality patient care. Self-motivated professional promoting attention to detail and the drive to resolve issues effectively. Calm and poised in the most stressful environments. Seeking the opportunity to join new organization in the role of Utilization Review or Nurse Case Management. I am skilled Utilization Review Nurse offering talents in continuous assessments and clinical records oversight. Pleasant individual with over 29 years in the nursing field. Ready to join new company that appreciates attention to detail and exemplary clinical review skills. Energetic individual offering over 15 years' experience in reviewing compliance standards and auditing charts. Astute Utilization Review Nurse knowledgeable in medical data gathering, analysis and authorization obtainment.

  • Continuous assessments
  • Utilization review
  • Patient transfers and transitions
  • Skilled in excel, power point, EMR, windows 360, teams.
  • Body mechanics knowledge
  • Broad medical terminology knowledge
  • Computerized charting specialist
  • Discharge planning
  • MCG
  • Interqual
  • Parental support
  • Neonatal care plans
  • Newborn health evaluations
  • Catheters
  • Patient discharging
  • Triaging
  • Life-sustaining machines
  • Taking vitals
  • Working collaboratively
  • Team building
  • First Aid/CPR/NRP
  • Planning
  • Communication
  • Friendly, positive attitude
  • Reliable and trustworthy
  • Coordination
  • Case management experience
  • Client documentation
  • Compassionate client care
  • Knowledge of state regulations
  • Behavior redirection
  • Organizational skills
  • Active listening
  • Multitasking
  • Critical thinking
  • Collaboration
  • Maintenance & minor Repair in-home equipment
  • Decision-making
  • Quality program protocols
  • Research community resources
  • Research grants available for treatment and therapies not covered under insurance
10/2009 to 01/2021
Case/Utilization Management Specialist Brightspring Health Services Bristol, TN,
  • Advocated for NICU members families to coordinate care and navigate resources within medicaid or commercial systems.
  • Contacted insurance carriers to obtain authorizations for INN provider services delivered to patients or assist in single case agreement for OON providers.
  • Reviewed patient admissions to determine medical necessity as directed by MCG criteria.
  • Managed medical necessary processes pertaining to denials and potential denials as outlined by insurance carriers using MCG and Optum's discharge planning guidelines.
  • Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
  • Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
  • Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
  • Determined medical necessity and cost-effectiveness of services through utilization review processes.
  • Collaborated with medical directors in group meetings to identify issues and find cost-effective solutions.
  • Utilized computerized Resource Electronic medical Records (EMR)
  • Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
  • Assessed patient conditions, monitored progression and failure to progress updating medical directors with observations and concerns.
  • Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues obtaining breast pumps immediately with INN DME and tips on successful pumping
  • Participated in continuing education programs and Optum required learn sources to enhance training and nursing knowledge.
  • Counseled patient families, providing emotional, psychological and spiritual support. Making appropriate referrals to social work team as needed
  • Answered parents questions and provided mailed materials for further information.
  • Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
  • Worked with facilities utilization management supplying approvals and potential denials facilitating peer to peers as needed.
  • Participation in innovation supplying and use 5 improvements for program
  • Became a Cultural Ambassador for UHG providing volunteer activities for local communities
08/2005 to 08/2009
Registered Nurse Case Manager Lowell General Hospital North Chelmsford, MA,
  • Advocated for patients by identifying insurance coverage, communicating care preferences to practitioners and verifying interventions met patients' treatment goals for Special needs children.
  • Developed appropriate care plans for at-risk individuals and high-risk families.
  • Optimized program resource utilization to prevent unnecessary hospital admissions.
  • Lowered costs while improving care quality by coordinating services and collaborating with dedicated healthcare team.
  • Determined and coordinated appropriate level of care to meet individual patient needs.
  • Informed patients and families of treatment options and at-home care strategies to reduce unnecessary burden on hospital resources.
  • Obtained recommendations for inpatient or outpatient level of care by discussing cases with physician advisor.
  • Collaborated in consults, patient care plans development, patient monitoring and evaluations.
  • Oversaw and minimized specialist queues with average of 100 new referrals per month.
  • Used facility EMR system to update patient records, transmit prescriptions and transfer files.
  • Assessed and reviewed patients for discharge and planning, including integrating services for patients requiring home care, home infusion and durable medical equipment (DME).
  • Actively participated in family and patient planning processes.
  • Collaborated with physicians on patient medications, medical needs and performance.
  • Developed patient care plans, including overall patient health assessments and evaluations.
  • Collaborated with physicians during medical rounds, updated treatment plans, and provided plan of care to patients and families.
  • Helped patients famlies navigate healthcare system and care options by educating on relevant subject areas and answering questions throughout treatment process.
  • Conducted yearly evaluations to address changes in patient needs, conditions and medications.
  • Collaboration with PCP, subspecialist, social work to ensure needs are met, making home visits when necessary with social work.
05/2003 to 07/2005
Home Health Registered Nurse Brookdale Senior Living Lewisville, TX,
  • Developed care plans, covering goals based on nursing diagnosis and incorporating therapeutic, preventive and rehabilitative nursing actions.
  • Utilized learned nursing skills for wound care, vital sign checking and medication assistance.
  • Resolved issues in the field by notifying the PCP immediately to determine the course of action.
  • Collected biological samples for routine laboratory testing to assist diagnostic processes.
  • Verified consistent delivery of compassionate care to patients with debilitating conditions, high tech Ventilator dependent children and adults, tube feeding, trach care and changes, arterial blood draws, IV medications, ostomy care.
  • Sterilized equipment and supplies using germicides to protect patients from infection.
  • Addressed patient care needs, collected vitals, dressed wounds and managed catheters.
  • Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans as needed.
  • Worked with vendors on provision of medical equipment, supplies and services.
  • Assisted patients with activities of daily living and functional mobility to increase comfort and quality of life if applicable.
  • Supported Hospice patients with activities of daily living and functional mobility to improve comfort and quality of life and pain management.
  • Charted changes in patient conditions and discussed concerns with supervising healthcare provider.
  • Completed initial assessments of patients and family to determine and address individual home care needs.
  • Administered prescribed medications and started intravenous fluids to address patient symptoms and underlying etiologies.
  • Assisted with personal care needs of clients in private homes while supporting patient independence and well-being.
05/2000 to 01/2003
NICU Staff Registered Nurse Southeastern Health Lumberton, NC,
  • Utilized valuable communication skills to deliver information to family members regarding patient treatment, care and medical options.
  • Formulated care plans for every individual neonatal intensive care patient, reviewing on daily basis to determine effectiveness.
  • Managed day-to-day routines for newborn babies by administering medication and fluids and checking vital signs regularly.
  • Delivered exceptional care to average of 6 neonatal ICU patients in 60 bed Level 3 NICU.
  • Stocked clinical workstations and procedure rooms with necessary supplies.
  • Assessed patients, documented observations and reviewed patient charts to determine care needs Treated patients with broad range of diagnoses, various congenital anomalies, and prematurity.
  • Instructed patients, families and caregivers on diagnoses, chronic disease management and medication self-management.
  • Managed all facets of telemetry, including PA catheters and arterials, vasoactive drug administration and titration, thrombolytic therapy, dysrhythmia interpretation, chest tube, feeding tube management, ostomy, pre and post-op care, obtaining all artery and venus blood work, mechanical ventilation.
  • Collaborated with doctors to plan post-treatment home care and prevent return hospitalization due to complications.
  • Collaborated with interdisciplinary healthcare professionals to create, implement and adapt individualized care plans.
08/1996 to 03/1998
Staff Nurse Me/Surg Bonsecour Venice Hospital City, STATE,

Was Staff RN with 2 LPN's and 1 CNA for Med/Surg unit patient pre and post surgery, endocrinology, hospice, respiratory, infectious disease, and pediatrics

10/1994 to 06/1995
Home Health RN Maxim Health Care Services City, STATE,

High tech pediatrics, and Adults, Hospice, shift work in various facilities, admissions, home set-ups.

10/1992 to 08/1993
Staff LPN Venice Hospital City, STATE,

LPN in short stay procedures, chemo, per-op and post op care, floated to CCU and ICU as needed

Education and Training
Expected in 08/1992
Diploma LPN: LPN
Sarasota Technical Institute - Sarasota, FL,
Expected in 1996
Associate of Science: Nursing
St. Petersburg College - Clearwater, FL
Expected in 01/2016
Certification: Case Management
Commission For Case Management Certification - Mount Laurel, NJ,
Activities and Honors
  • Member, American Nursing Association, North Carolina Nursing Association, Certified Case Manager Association
  • Recognition for services in Sarasota County Medical Society 1992
  • Presidents list at St. Petersburg College 1993-1995
  • Honor Graduate St. Petersburg College 1996
  • Innovation participant UHG supply 5 use ideas for improve family outreach, provider relations, avoiding provider abrasion.
  • Received UHG Bravo's 20/year
Additional Information


8/1992- Licensed Practical Nurse Fl: PN 1080991

8/1996- Registered Professional Nurse Fl: RN 3097362

2/2000- Registered Professional Nurse NY-513141

5/2012-Registered Nurse NC-252983

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Resume Strength

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Resume Overview

School Attended
  • Sarasota Technical Institute
  • St. Petersburg College
  • Commission For Case Management Certification
Job Titles Held:
  • Case/Utilization Management Specialist
  • Registered Nurse Case Manager
  • Home Health Registered Nurse
  • NICU Staff Registered Nurse
  • Staff Nurse Me/Surg
  • Home Health RN
  • Staff LPN
  • Diploma LPN
  • Associate of Science
  • Certification

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