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Utilization Review Nurse Resume Example

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Jessica Claire
  • , , 100 Montgomery St. 10th Floor
  • Home: (555) 432-1000
  • Cell:
  • resumesample@example.com
Professional Summary

Dependable Utilization Review Nurse promoting over 18 years of expertise in healthcare industry. Knowledgeable in admissions and stay reviews.

Skills
  • Strong clinical judgment

  • EMR

  • Documentation and reporting

Skills

Strong clinical judgment

:

EMR

:

Documentation and reporting

:
Work History
Utilization Review Nurse, 10/2019 to 12/2020
Johns Hopkins MedicineGlen Burnie, MD,

Job responsibilities: pre-certified inpatient and observation hospital stays for patients admitted to our facilities, faxed clinical to payers, performed initial, concurrent and retro reviews on cases, discussed cases with the attending physician to request upgrade to inpatient level of care if the case met medical necessity criteria based on Interqual Care Guidelines or a downgrade to observation level of care if the case did not meet inpatient level of care criteria based on review of the Interqual Care Guidelines, discussed denied cases with the attending physician, scheduled peer to peers discussion for the attending physician, entered case approval authorizations and denials into the computer, made case outreach calls to providers to resolve case issues and received inbound calls from providers to resolve any case issues. Submitted eligible cases to R1 Physician Advisory Group to complete peer to peer discussions for our physicians.

Utilization Review Nurse, 04/2017 to 01/2019
Johns Hopkins MedicineBradenton, FL,

Job responsibilities: pre-certified inpatient and observation hospital stays for patients admitted to our facilities, faxed clinical to payers, performed initial, concurrent and retro reviews on cases, discussed cases with the attending physician to request upgrade to inpatient level of care if the case met medical necessity criteria based on Milliman Care Guidelines or a downgrade to observation level of care if the case did not meet inpatient level of care criteria based on review of the Milliman Care Guidelines, discussed denied cases with the attending physician, scheduled peer to peers discussion for the attending physician, entered case approval authorizations and denials into the computer, made case outreach calls to providers to resolve case issues and received inbound calls from providers to resolve any case issues.

Prior Authorization Nurse/Utilization Review Nurse, 11/2013 to 03/2017
TotalmedBethesda, MD,

Job responsibilities: (Prior Authorization Registered Nurse) reviewed member and providers requests for medical procedures, medical equipment and medication to determine if the request met medical necessity criteria for coverage based on review of the members benefit certificate/document, applicable medical policies, FDA drug guidelines, NCCN Compendium guidelines as well as additional source guidelines, drafted approval and denial letters based on case determinations, forwarded cases that did not meet medical necessity criteria to the medical director for denial review, completed administrative denials on services that were excluded by the members benefit certificate/document.

Job responsibilities: (Utilization Review Registered Nurse) performed reviews on initial, concurrent and retro inpatient hospital stays for members, pre-certified inpatient skilled nursing facility stays, pre-certified requests for long term acute care inpatient stays, pre-certified requests for surgical procedures and requests for inpatient hospice stays, answered incoming provider phone calls and took verbal clinical updates via the telephone, called hospitals to obtain the members admission/discharge dates, called the case manager/utilization review department(s) to request clinical and to inform them of authorized days.

Prior Authorization Nurse, 05/2010 to 09/2013
Elderwood At WaverlyLowman, NY,

Job responsibilities: (Prior Authorization Registered Nurse) reviewed member and providers requests for medical procedures, medical equipment and medication to determine if the request met medical necessity criteria for coverage based on review of the members benefit certificate/document, applicable medical policies, FDA drug guidelines, NCCN Compendium guidelines as well as additional source guidelines, drafted approval and denial letters based on case determinations, forwarded cases that did not meet medical necessity criteria to the medical director for denial review, completed administrative denials on services that were excluded by the members benefit certificate/document.

Job responsibilities: (Utilization Review Registered Nurse) performed reviews on initial, concurrent and retro inpatient hospital stays for members, pre-certified inpatient skilled nursing facility stays, pre-certified requests for long term acute care inpatient stays, pre-certified requests for surgical procedures and requests for inpatient hospice stays, answered incoming provider phone calls and took verbal clinical updates via the telephone, called hospitals to obtain the members admission/discharge dates, called the case manager/utilization review department(s) to request clinical and to inform them of authorized days.

RN Admissions Nurse, 04/2009 to 10/2009
Arkansas HospiceCity, STATE,

Met with patients and their families to discuss hospice services, completed legal paperwork to admit patients to hospice services, assessed patients, took vital signs, recorded medications being administered to patients and created patient care plans for treatment.

Education
No Degree: Nursing Pre Requisites, Expected in
Pulaski Technical College - North Little Rock AR,
GPA:
Associate of Arts: Registered Nursing, Expected in 12/2007
Baptist School Of Nursing - Little Rock AR,
GPA:
Cerificate: Licensed Practical Nursing, Expected in 07/2003
Baptist School Of Nursing - Little Rock AR,
GPA:

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Resume Strength

  • Personalization
  • Strong Summary
  • Target Job

Resume Overview

School Attended
  • Pulaski Technical College
  • Baptist School Of Nursing
  • Baptist School Of Nursing
Job Titles Held:
  • Utilization Review Nurse
  • Utilization Review Nurse
  • Prior Authorization Nurse/Utilization Review Nurse
  • Prior Authorization Nurse
  • RN Admissions Nurse
Degrees
  • No Degree
  • Associate of Arts
  • Cerificate

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