Professionally trained Registered Nurse with experience ensuring high standards of culturally competent care for a wide variety of patients with diverse needs. Career Objective is to obtain a position as an Utilization Review Nurse where my special skills can be used to their fullest potential to help improve the standards of care.
•Determined medical necessity of the requested treatment.
Determined appropriateness and medical necessity of hospitalization and requested treatment (s) based on plan's guidelines, policies, Milliman, and medical director review, if needed. Also, includes observation status
Responsible for requesting clinical information for concurrent review with strict adherence to URAQ guidelines
Responsible for presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging any peer-to-peer reviews, if requested by hospitalist, attending, or primary care physician
Assisted and/or provided facility interdisciplinary teams benefit information for in network providers/facilities, DME, home healthcare, acute, sub-acute rehab, skilled nursing facilities, and out-of-network benefits, if needed
Communicated frequently with assigned case managers for unplanned admissions, inpatient status, and discharge plan with orders
Collaborated with assigned case manager to identify members frequent hospital readmissions
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