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Utilization Review Nurse Case Manager Resume Example

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Jessica Claire
  • , , 100 Montgomery St. 10th Floor
  • H: (555) 432-1000
  • C:
  • resumesample@example.com
  • Date of Birth:
  • India:
  • :
  • single:
Professional Summary

Smart Utilization Review Nurse considered critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare guidelines. Known for having great rapport with providers and insurance carriers.

Accomplishments

    Received Clinical Star of the Quarter for being a team leader and worker, always assisting those that need whether it is on the unit or over the phone, pick up extra shifts as Hospital Supervisor and always assist in Code Blue.

Skills
  • Performance Tracking and Evaluation
  • Teamwork and Collaboration
  • Proficient in InterQual
  • Complex Problem Solving
  • Verbal and Written Communication
  • Documentation and Reporting
  • MS Office
  • Work Planning and Prioritization
  • Interpersonal Relations
  • Decision Making
Work History
Utilization Review Nurse/Case Manager, 03/2019 to Current
Baptist Health South Florida FL, State,
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Served as subject matter resource, providing information related to Discharge planning situations.
  • Facilitated workgroup meetings with Interdisciplinary teams to find effective solutions to issues.
  • Supervised and maintained all utilization review documentation through InterQual.
  • Performed admission reviews based for medical necessity based upon InterQual specification.
  • Performed prior authorization review of services requiring notification.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Defined clear targets and objectives and communicated to other team members.
  • Communicated best practices among on-site and external personnel to align efforts and goals.
  • Supported or performed clinical appeals.
Registered Nurse, Float Pool, 05/2018 to 03/2019
Brookdale Senior Living Lenoir, NC,
  • Provided direct patient care, stabilized patients and determined next course of action.
  • Managed care from admission to discharge.
  • Administered medications via oral, IV and intramuscular injections and monitored responses.


  • Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
  • Monitored patient condition by interpreting and tracking EKG readings, identifying irregular telemetry readings and updating team members on changes in stability or acuity.
  • Oversaw delivery of care for patients on medical-surgical unit, providing direct care, delegating nursing assignments, and supervising team comprised of nurses, LPNs, technicians and unit clerks.
  • Monitored patient reactions to drugs and carefully documented findings.
  • Reviewed post-operative orders and continuously monitored patients' post-operative vitals, set up PCA and fluids and oriented patients to unit.
  • Maintained quality care and comfort for patients with heart failure, pulmonary hypertension and other conditions.
  • Updated patient charts with data such as medications to keep records current and support accurate treatments.
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
  • Secured controlled narcotics and distributed medication on schedule to meet patient needs and minimize misuse opportunities.
  • Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
  • Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
  • Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
  • Taught patients how to improve lifestyle choices, dramatically reducing chance of symptom reoccurrence.
  • Audited charts and reviewed clinical documents to verify accuracy.
  • Minimized hospital stays with recovery-centered approaches, reducing average in-patient stay length.
  • Implemented medication and IV administration, catheter insertion and airway management.
  • Provided exceptional care to high-acute patients needing complex care such as ventilator management, extensive wound care and rehabilitation.
Home Health Registered Nurse, 05/2015 to 03/2018
Christus Health Hawkins, TX,
  • Traveled to patients' homes on daily basis to assess health conditions and provide superior level of nursing care.
  • Provided physical assessments, medication and chronic disease management to home health patients.
  • Advised and coached patients progressing from hospitals, rehab facilities and other medical organizations to at-home treatment settings.
  • Trained, guided, supported and supervised home health aide care providers.
  • Contacted patient's MD when issues arose with at-home patients in effort to find effective resolutions.
  • Incorporated therapeutic, rehabilitative and nursing goals into detailed, individualized care plans based on diagnoses.
  • Educated patients on use and benefits of equipment such as home blood pressure cuffs and glucose meters.
  • Informed physicians of any changes to patients' health or concerns observed during home visits.
  • Introduced changes to patient care plans based on regular evaluations and patient changes.


  • Took samples to complete diagnostic and routine assessment tests.
  • Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
  • Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.
  • Delivered after-hours care to patients based on strict role-call rotations.
  • Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
Utilization Review Nurse/Nurse Case Manager, 06/2012 to 03/2014
Opelousas General Hospital City, STATE,
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Devise or identify solutions for irregular requests and issues.
  • Supported or performed clinical appeals.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Facilitated workgroup meetings with IDTs to find effective solutions to issues.
  • Performed admission reviews based for medical necessity based upon InterQual specification.
  • Coordinated patient care and needs with Physician.
Registered Nurse, ICU, 06/2011 to 06/2013
Opelousas General Health System City, STATE,
  • Managed care from admission to discharge.
  • Provided direct patient care, stabilized patients and determined next course of action.
  • Administered medications via oral, IV and intramuscular injections and monitored responses.


  • Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
  • Updated patient charts with data such as medications to keep records current and support accurate treatments.
  • Monitored patient reactions to drugs and carefully documented findings.
  • Secured controlled narcotics and distributed medication on schedule to meet patient needs and minimize misuse opportunities.
  • Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
  • Organized and managed care of patients undergoing various therapies and procedures.
  • Managed quality care for patients with heart failure, end-stage renal disease and coronary artery disease.
  • Monitored patient condition by interpreting and tracking EKG readings, identifying irregular telemetry readings and updating team members on changes in stability or acuity.
  • Implemented medication and IV administration, catheter insertion and airway management.
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
  • Reviewed post-operative orders and continuously monitored patients' post-operative vitals, set up PCA and fluids and oriented patients to unit.
  • Audited charts and reviewed clinical documents to verify accuracy.
  • Advised patients and caregivers of proper wound management, discharge plan objectives, safe medication use and disease management.
  • Maintained quality care and comfort for patients with heart failure, pulmonary hypertension and other conditions.
Education
No Degree: , Expected in
to
University of Louisiana At Lafayette - Lafayette, LA
GPA:
Associate of Science: Nursing, Expected in 05/2011
to
Louisiana State University At Alexandria - Alexandria, LA
GPA:
Practical Nursing : Nursing, Expected in 05/2006
to
Louisiana Technical College - Hessmer, LA,
GPA:
High School Diploma: , Expected in 05/2003
to
Chataignier High School - Chataignier, Louisiana,
GPA:
Certifications
  • ACLS
  • PALS
  • CPI
  • CPR

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Resume Overview

School Attended
  • University of Louisiana At Lafayette
  • Louisiana State University At Alexandria
  • Louisiana Technical College
  • Chataignier High School
Job Titles Held:
  • Utilization Review Nurse/Case Manager
  • Registered Nurse, Float Pool
  • Home Health Registered Nurse
  • Utilization Review Nurse/Nurse Case Manager
  • Registered Nurse, ICU
Degrees
  • No Degree
  • Associate of Science
  • Practical Nursing
  • High School Diploma