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registered nurse medical claims review resume example with 16 years of experience

Jessica Claire
  • , , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
  • :
Summary

Highly-motivated employee with desire to take on new challenges. Strong work ethic, disciplined (as I have worked from home for 13+ years), adaptability and exceptional interpersonal skills along with time management and multitasking abilities. Adept at working effectively unsupervised and quickly mastering new skills.

Skills
  • Claims Processing
  • Critical Thinking
  • Claims Evaluation
  • Attention to Detail
  • Compassionate and Caring
  • Accurate Documentation
  • Information Confidentiality
  • Verbal and Written Communication
  • Active Listening
Experience
Registered Nurse, Medical Claims Review, 05/2016 to Current
GeisingerChampion, PA,
  • Processed claims for payment or forwarded to appropriate personnel for further investigation
  • Stayed current on HIPAA regulations, benefits claims processing, medical terminology and other procedures.
  • Inputted data into the system, maintaining accuracy of provider coding information and reported services.
  • Accurately processed large volume of medical claims every shift.
  • Evaluated pending claims to identify and resolve problems blocking auto-adjudication.
  • Based payment or denials of medical claims upon well-established criteria for claims processing.
  • Reviewed administrative guidelines whenever questions arose during processing of claims.
  • Used contract notes and processing manual to correctly apply group-specific classifications to claims.
  • Examined claims, records and procedures to grant approval of coverage.
  • Checked documentation for appropriate coding, catching errors and making revisions.
  • Retained strong medical terminology understanding in effort to better comprehend procedures.
RN Case Manager, 07/2010 to 05/2016
Memorial Healthcare SystemWeston, FL,
  • Developed patient care plans, overall patient health assessments and evaluations.
  • Actively participated in family and patient planning processes.
  • Determined and coordinated appropriate level of care to meet individual patient needs.
  • Incorporated appropriate nursing methods to create individualized care plans.
  • Obtained and followed physician recommendations for both inpatient and outpatient care depending on diagnosed recovery process.
  • Conducted [Timeframe] evaluations to address changes in patient needs, conditions and medications.
Registered Nurse, 08/2009 to 07/2010
HcaRichmond Hill, GA,
  • Updated medical records with current vitals, behavioral observations and medication details.
  • Monitored patient status during treatment and reported variances and adverse reactions to care teams.
  • Collected and analyzed patient data before, during and after treatments and documented information in patient medical records.
  • Administered medications to [Number] patients per day as directed by individual treatment plans.
  • Counseled patients on infusions and possible side effects to promote treatment compliance.
  • Modified patient treatment plans as indicated by patients' responses and conditions.
  • Administered oral, IV and intra-muscular medications and monitored patient reactions.
  • Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns.
  • Observed strict safety measures, including checking medication dosages before administration to patients.
  • Stocked clinical workstations and procedure rooms with necessary supplies.
  • Delivered information regarding care and medications to patients and caregivers in comprehendible terminology.
  • Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches.
Registered Nurse, Medical-Surgical Unit, 06/2007 to 08/2009
Benedictine HospitalCity, STATE,
  • Administered medications and treatments as directed and as appropriate for patient's medical care in collaboration with multi-disciplinary team.
  • Assessed patient needs, prioritized treatment, maintained patient flows and assisted physicians with non-invasive procedures.
  • Administered medications and treatments, monitoring patients for reactions and side effects.
  • Adhered to infection control procedures to facilitate safe, clean patient environment.
  • Evaluated patients, recognized and addressed complications and coordinated treatment with other members of critical care team.
  • Maintained thorough, accurate and confidential documentation in electronic medical records.
  • Acted as patient advocate and implemented total patient care through team nursing process.
  • Recorded patient condition, vital signs, recovery progress and medication side effects.
  • Monitored and managed various treatment and care interventions.
  • Advocated for patients by supporting and respecting basic rights, values and beliefs.
  • Administered medications, tracked dosages and documented patient conditions.
  • Updated charts throughout shifts with current, accurate information to maintain strict recordkeeping standards.
  • Provided patient and family health education focusing on self-management, prevention and wellness.
  • Assessed and prepared patients for procedures, performing initial and ongoing patient assessments.
  • Observed patient's heart rate, blood pressure and respiration for signs of distress.
  • Implemented pre, intra- and post-care, evaluating response to clinical interventions with progression toward discharge.
  • Maintained personal and team compliance with medication administration standards and patient care best practices.
  • Oversaw patient admission and discharge processes to coordinate related paperwork.
  • Created, implemented and evaluated patient care plans with medical team.
  • Promoted safe and calm environment for complex patients by keeping services, supplies and necessary equipment on hand.
  • Conducted intake assessments with patients and relatives to gather case history.
Education and Training
Bachelor of Science: Nursing, Expected in 06/2015 to Capella University - Minneapolis, MN
GPA:
Associate of Science: Nursing, Expected in 05/2007 to Ulster County Community College - Stone Ridge, NY
GPA:
Associate of Applied Science: Executive Assistant And Executive Secretary, Expected in 05/1983 to Ulster County Community College - Stone Ridge, NY
GPA:
High School Diploma: , Expected in 06/1981 to Saugerties Senior High School - Saugerties, NY
GPA:

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Resume Overview

School Attended

  • Capella University
  • Ulster County Community College
  • Ulster County Community College
  • Saugerties Senior High School

Job Titles Held:

  • Registered Nurse, Medical Claims Review
  • RN Case Manager
  • Registered Nurse
  • Registered Nurse, Medical-Surgical Unit

Degrees

  • Bachelor of Science
  • Associate of Science
  • Associate of Applied Science
  • High School Diploma

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