Clinical Nurse Consultant Utilization Management Resume Example

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(555) 432-1000,
Montgomery Street, San Francisco, CA 94105
Professional Summary

Registered Nurse with 35 years of experience in direct patient care and utilization management within hospital and managed care settings. Clinical experience spans across NICU, PICU, ECMO, and PACU environments. Passionate about providing care focused on quality, disease prevention, and health promotion. Recognized consistently for extensive clinical knowledge, attention to detail, thorough documentation, teamwork, and flexibility.

  • Knowledge of managed Medicaid
  • Interpersonal and written communication
  • Documentation and reporting
  • Physician consultations
  • Patient care plans
  • Discharge planning coordination
  • Relationship development
  • MS Office / MCG Criteria / McKesson INTERQUAL
  • Critical thinking and problem resolution
Pennsylvania College of Health Sciences Lancaster, PA Expected in 12/1983 Associate of Science : Nursing - GPA :

Received a Nursing Diploma

Work History
Aetna Inc. - Utilization Management Nurse Consultant
WA, State, 08/2017 - 05/2019
  • Utilized clinical experience and skills in collaboration to assess, plan, implement, coordinate, monitor, and evaluate options to facilitate appropriate use of healthcare services for members
  • Gathered clinical information for inpatient admissions and applied appropriate MCG criteria, practice guidelines, and clinical judgement to render coverage determination along continuum of care
  • Communicated with providers to facilitate care and treatments
  • Identified member for referral opportunities to integrate with other products, services, and programs
  • Identified opportunities to promote quality effectiveness of healthcare services
  • Consulted with internal and external constituents to lend expertise in coordination and administration of benefit management
  • Organized and presented clinical information regarding treatments for daily patient rounds
Allina Health Systems - Utilization Management Coordinator
Fridley, MN, 09/2007 - 02/2017
  • Optimized revenue for assigned patient admissions
  • Managed 65-85 bed assignment
  • Performed admission reviews based on medical necessity utilizing McKesson criteria, MDS regulations, practice guidelines, and clinical judgement
  • Obtained authorizations from multiple insurance carriers for various levels of care
  • Supervised and maintained all utilization review documentation through multiple databases including EPIC EMR
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services
  • Supported or performed clinical appeals
  • Submitted cases to assigned medical director for criteria failures and helped facilitate resolutions and approvals
  • Collaborated with case managers and discharge coordinators on evaluation of care plan outcomes
Us Oncology, Inc. - Registered Nurse Clinician
Odessa, TX, 01/1984 - 09/2007
  • Evaluated patient care needs and prioritized treatment to maintain patient flow as follows: Coronary Care Unit 9/2006 to 9/2007, ECMO Team 9/2005 to 9/2006, Post Anesthesia Care Unit Ambulatory Surgery 5/2003 to 9/2005, Neonatal Intensive Care Unit 5/1986 to 5/2003, General Medicine/Surgery 1/1984 to 5/1986
  • Observed, recorded and evaluated patient symptoms, reactions and daily progress to inform assigned physicians of concerns
  • Provided exceptional care to acutely ill neonates, children, and adults needing complex care such as resuscitation, continuous monitoring, ventilator management, ECMO, pre- and post-procedure care, and chronic illness
  • Delivered medications via oral, IV and intramuscular injections, monitoring responses to address any new concerns
  • Educated family members and caregivers on patient care instructions
  • Documented all elements of nursing assessment, including treatment, medications and IVs administered, discharge instructions, and follow-up care
  • Performed ongoing assessments to evaluate mental health needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care
  • Collected blood, tissue and other laboratory specimens and prepared for lab testing
  • Participated in continuing education programs
  • Provided skilled, timely and level-headed emergency response to critically-ill patients
  • Managed daily comprehensive patient care from admission to discharge, including assessments, care planning, health education, and discharging support
  • Supervised medical management of critically ill neonates in community hospital settings to stabilize and safely transport to Level IV NICU for additional care
  • Served as charge nurse, shift manager, team leader, preceptor, and general unit resource nurse
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities to prevent further disability
  • Audited charts and reviewed clinical documents to verify accuracy
  • Explained course of care and medications, including side effects to patients and caregivers in easy-to-understand terms
  • Coordinated and performed continuing education and training sessions to medical staff, nursing staff, respiratory therapists, transport team, and paramedics
  • Organized and managed care of patients undergoing various therapies and procedures
  • Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions

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Resume Overview

School Attended
  • Pennsylvania College of Health Sciences
Job Titles Held:
  • Utilization Management Nurse Consultant
  • Utilization Management Coordinator
  • Registered Nurse Clinician
  • Associate of Science

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