compliance utilization management nurse resume example with 11 years of experience

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

LVN with Bachelors in Arts. Utilization, skilled nursing and management experience. Highly motivated and willing to learn all necessary skill to complete all and any task for the role of Utilization management. Worked on different systems with knowledge of day to day operations in utilization management. I'm a good team player and participate in team building.

Knowledgeable professional expert in streamlining processes, supervising team members and performing any task given. Committed go-getter with team player attitude and ability to remain calm in stressful situations.

  • Team player with excellent interpersonal and telephone communication skills.
  • Interacting with various departments such as customer services, provider relations and contracting.
  • Planning and coordination
  • Supervision
  • MS Office
  • Worked in a fast paced environment
  • Team management
02/2023 to 04/2023 Sr. Clinical Claims Review Nurse Centene Corporation | Fort Myers, FL,
  • Researched and reviewed information to determine validity of insurance claims and contacted companies and customers about decisions.
  • Resolved claims by approving or denying documentation, calculating benefits due.
  • Documented specific claims by completing and recording forms, reports and logs.
  • Maintained knowledge of policies and procedures and insurance coverage benefit levels, eligibility systems and verification processes.
  • Communicated with other departments to establish action plans and manage open claims to closure.
05/2022 to 01/2023 Manager Utilization Management Universal Health Services | Portland, OR,
  • 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.
  • Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
  • Referred cases to secondary review for failure to meet medical necessity criteria.
  • Managed inpatient processes pertaining to denials and potential denials as outlined by insurance carriers.
  • Resolved conflicts between physicians, nurses and administrative staff to maintain optimal workflows.
  • Facilitated peer-to-peer conflict resolution.
  • Participated in flash meetings with department heads to discuss census information, admissions and discharges for residents.
  • Drove process, efficiency and quality improvements, resulting in 10% increase in patient discharge times.
05/2021 to 05/2022 Compliance Utilization Management Nurse Universal Health Services | San Angelo, TX,
  • Direct the day-to-day operations of the Regulatory Affairs (Medicare) Unit in the most effective manner to meet Plan, department, and unit objectives while ensuring quality and accuracy of the work. Implement standardized processes to maximize efficiency.
  • Lead, guide, manage, and as appropriate attend in the participation of relevant committees and work groups, make presentations, prepare reports, data, or other materials. These may include, but are not limited to internal workgroups, workgroups convened by trade associations
  • Followed protocols regarding quality assurance, biohazards, infection control, charting and emergencies.
  • Participated in continuing education programs and workshops to enhance training and nursing knowledge.
  • Coordinated with healthcare team to establish, enact and evaluate patient care plans.
  • Identify potential Medicare risks, non-compliance and/or alleged violations within the Plan, and work with Compliance Audit & Oversight Unit to develop and implement department and unit corrective action plans (CAPs) for resolution
05/2014 to 04/2021 Supervisor Utilization Management Alpha Residential Inc. | City, STATE,

I am responsible for collaborating with clinical and non-clinical personnel providing timely care which complies with generally accepted standards of clinical practice. This includes but not limited to assigning work schedules, delegating reviews, providing direction on review priorities, meeting the demands of internal and external partners, and ensuring staff achieve performance goals and adherence to company policies. In addition, individuals in this assignment must have continuing responsibility for all the following functions:

  • Ensures that the UM team is properly trained to conduct medical necessity reviews on incoming pre-service/prior authorization, on routine and expedited referrals requests in compliance with Federal, State, Health Plan and NCQA standards.
  • Assures staff accountability through performance evaluation and periodic monitoring of work productivity and quality.
  • Ensures UM team documents on the medical management system timely, all supporting clinical information, outreach attempts and criteria used to make a determination.
  • Monitor, track, and report any inappropriate referral patterns to the UM Medical Director.
  • Serves as a subject matter expert on appropriate use, interpretation and documentation of clinical criteria in the review process using NCD, LCD, Health Plan Medical Guidelines, MCG, NCCN, etc.
  • Utilized active listening skills to quickly resolve problems and escalated larger issues to UM Manager.
  • Provided effective quality control oversight and eliminated downtime to maximize revenue.
06/2011 to 03/2014 Charge Nurse Company Name | City, State,
  • Total patient care with specialized care for patients with trachs and GT tubes,med nebulizer treatments.
  • Provided continuous assessment of patients in acute care unit from admission to discharge.
  • Precepted new staff nurses to provide education on hospital policies and procedures, patient care skills, medical procedures and techniques, and patient assessments and interventions.
  • Managed patient admissions and hospital discharges to various settings, including home care, rehabilitation or self-care.
  • Utilized Situation-Background-Assessment-Recommendation (SBAR) and electronic health records to document treatments and patient status observations.
  • Administered prescribed medications to address patient symptoms and underlying etiologies.
  • Supported physicians and consultants with tests and procedures.
  • Educated patients on wound and disease self-management techniques.
  • Educated patients on disease prevention and health maintenance.
  • Delivered high level of care to every patient.
  • Documented and evaluated effectiveness of care plans and interventions.
  • Delegated and prioritized tasks, streamlining all steps in rapid response situations.
02/2010 to 05/2011 Charge Nurse Company Name | City, State,
  • In charge of patients who are handicapped and on Vents with the help of Registered Nurse.
  • Execute all paperwork for DME products.
  • Organized and delegated tasks during rapid response and high-pressure code situations.
  • Utilized Situation-Background-Assessment-Recommendation (SBAR) and electronic health records to document treatments and patient status observations.
  • Educated patients, caregivers, and families on diagnoses, treatment and disease prevention.
  • Created and implemented care plans after reviewing patients' imaging and test results, working closely with other members of interdisciplinary team.
  • Administered prescribed medications and started intravenous fluids to address patient symptoms and underlying etiologies.
  • Supported physicians and consultants with tests and procedures.
  • Monitored patient status and treatment progress, reporting observations to physicians.
Education and Training
Expected in 09/2020 Basic Life Support | American Heart Association, Highland, CA, GPA:
Expected in 08/2010 Licensed Vocational Nurse | Nursing Summit College, Colton, CA GPA:
Expected in 09/2008 Pharmacy Technician | Pharmacy San Bernardino Adult School, San Bernardino, CA GPA:
Expected in 05/1985 Bachelor of Arts | Economics Veerasaiva College, India, GPA:

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Resume Overview

School Attended

  • American Heart Association
  • Summit College
  • San Bernardino Adult School
  • Veerasaiva College

Job Titles Held:

  • Sr. Clinical Claims Review Nurse
  • Manager Utilization Management
  • Compliance Utilization Management Nurse
  • Supervisor Utilization Management
  • Charge Nurse
  • Charge Nurse


  • Basic Life Support
  • Licensed Vocational Nurse
  • Pharmacy Technician
  • Bachelor of Arts

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