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Concurrent Review Nurse Resume Example

Resume Score: 70%

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CONCURRENT REVIEW NURSE
Professional Summary

Fifteen years of clinical experience in primary care including Medical Surgical and Neonatal ICU. Over 11 years of experience in Utilization Review, Discharge Planning working directly with Interqual/ Milliman and DRGS. Familiarity with ICD and CPT coding. Experience with HEDIS reviews, Medicaid and Medicare. Worked remotely for the past 10 years and have excellent autonomous analytical and decision making skills.

Licenses

RN license in the state of Delaware and Pennsylvania.

McKesson Certified in 2001.

Skill Highlights
  • Able to review and analyze medical records efficiently and quickly to ensure timely Utilization Review.
  • Excellent documentation skills of pertinent information to ensure appropriate utilization management
  • Experience with following all HIPAA laws while working in a remote setting with confidential information.
  • Skilled knowledge of Neonatal/Pediatric/Adult Healthcare
  • Extensive knowledge and experience with discharge planning ensuring proper care of members
Professional Experience
DPCI/Aetna Medicaid CompanyJuly 2013 to CurrentConcurrent Review Nurse
Newark, DE

Perform daily utilization review and discharge planning for medicaid members in acute and sub acute settings. Present cases to the medical team including medical directors and case managers to coordinate timely and appropriate care. Developed a team approach regarding daily reviews which was adopted by the Utilization Management team.

Highmark Blue CrossDecember 2006 to June 2013Utilization Management R.N.
Wilmington , DE

Conduct utilization management review remotely on a daily basis applying Interqual criteria. Interact with medical directors, case managers and the behavior health to ensure successful outcomes for the patient. Developed new systems and policies to aid in streamlining work processes.

Aetna/Keystone Mercy/BCBSDEJanuary 2003 to January 2006Utilization Management/HEDIS nurse
Newark, DE/PA

I worked temporary positions in the insurance industry conducting HEDIS reviews for Aetna and provided utilization management for Keystone Mercy and BCBSDE using Interqual and Milliman criteria for per diem and DRG facilities.

Christiana Care Health SystemMarch 1993 to January 2003Neonatal Intensive Care Nurse
Newark, DE

Provided for neonates in a clinical setting. During time at Christiana I also obtained a weekend Utilization Review position and became McKesson certified. The position enabled me to transition out of the clinical setting to the Utilization Management area.

VNAJanuary 1992 to March 1993Visiting Nurse/Home Healthcare
West Chester, PA
Mercy Fitzgerald HospitalJune 1989 to December 1990Medical Surgical RN
Darby, PA
Education and Training
Delaware County Community College1989ASN: NursingMedia, PA, USA
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Resume Overview

Companies Worked For:

  • DPCI/Aetna Medicaid Company
  • Highmark Blue Cross
  • Aetna/Keystone Mercy/BCBSDE
  • Christiana Care Health System
  • VNA
  • Mercy Fitzgerald Hospital

School Attended

  • Delaware County Community College

Job Titles Held:

  • Concurrent Review Nurse
  • Utilization Management R.N.
  • Utilization Management/HEDIS nurse
  • Neonatal Intensive Care Nurse
  • Visiting Nurse/Home Healthcare
  • Medical Surgical RN

Degrees

  • ASN : Nursing

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