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Utilization Review Nurse Resume Example

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UTILIZATION REVIEW NURSE
Professional Summary

Dependable Utilization Review Nurse promoting over ten years of expertise in healthcare industry. Knowledgeable in admissions and stay reviews. Considered to be a critical thinker and a problem-solver due to dynamic patient care planning and understanding of Medicare guidelines. Known for having great rapport with providers and insurance carriers.

Licenses

Alaska RN License - # 33727

Work History
Company Name - Utilization Review NurseCity, State11/2018 - Current
  • Submitted cases to Keppro for criteria failures and helped facilitate resolutions and approvals.
  • Supervised and maintained all utilization review documentation through EPIC and Interqual.
  • Obtained authorizations from multiple insurance carriers for various levels of care.
  • Facilitated workgroup meetings with Micosoft Teamss to find effective solutions to issues.
  • Performed admission reviews based for medical necessity based upon INTERQUAL specification.
  • Served as subject matter resource, providing information related to Admission, Inpatient, Observation, Outpatient situations.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Supported or performed clinical appeals through Peer to Peer facilitation and Follow up with providers and submissions to billing team.
  • Performed triage on all incoming patients and determined severity of injuries and illnesses.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
Company Name - RN Case ManagerCity, State04/2017 - 11/2018
  • Educated family members and caregivers on patient care instructions.
  • Maintained highest levels of patient satisfaction, generating referrals to maintain productivity levels for Inpatient rehabilitation unit.
  • Managed care from admission to discharge, including patient assessments, care planning, health educations and discharging support to provide comprehensive care to over twenty patients daily.
  • Addressed disruptions in patient care, including delays in discharge, postponed procedures and discharge equipment unavailability.
  • Communicated with healthcare team members to plan, implement and enhance treatment strategies.
  • Partnered with physicians, social workers, activity therapists, nutritionists and case managers to develop and implement individualized care plans and documented all patient interactions and interventions in electronic charting systems.
  • Applied nursing expertise to meet needs of Adult patients in challenging Alaskan environment.
Company Name - Critical Care Registered NurseCity, State08/2014 - 04/2017
  • Operated critical care equipment to keep patients stable and promote recovery.
  • Delivered outstanding patient care in Adult critical care units.
  • Assisted patients initially and every 15 minutes to 1 hour over a 12 hour shift to maintain current understanding of conditions and presentations.
  • Counseled patients and families on treatments and care options, including discharge and home care instructions.
  • Delivered top-notch care exceeding department, hospital and Joint Commission standards.
  • Responded rapidly to critical codes to coordinate stabilization treatments and restore vital functions.
  • Documented work in EPIC and updated patients' charts with orders and observations.
  • Completed diagnostic tests and patient assessments to evaluate treatment progress.
  • Administered medications to treat patients' symptoms and address underlying disease progression.
  • Protected critically ill patients from unnecessary risks by limiting visitors, using proper PPE and using strong infection control procedures.
  • Managed needs of chronically ill and acute patients with well-coordinated treatment strategies.
  • Worked with intubated and ventilated patients, monitoring and reporting on conditions to maintain stats within optimal levels.
  • Personalized bedside care and interactions based on cultural backgrounds of different patients.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities to prevent further disability.
  • Triaged patients and delegated treatment needs to qualified staff and specialized departments.
  • Assessed and managed various patient treatments for numerous patient diagnoses from sepsis to acute respiratory distress.
  • Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
  • Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
  • Implemented interventions, including medication and IV administration, catheter insertion and airway management.
  • Trained new nurses in proper techniques, care standards, operational procedures and safety protocols to optimize performance and safety.
  • Trained and coached new employees on protocols and best practices to promote ideal patient outcomes.
  • Delivered high level of quality care to diverse populations while overseeing patient admission and triaging based on acuity and appropriate department admission.
Company Name - RN, Critical CareCity, State03/2009 - 11/2013
  • Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
  • Delivered outstanding care to patients with various diagnoses and managed care from treatment initiation through to completion.
  • Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
  • Trained new nurses in proper techniques, care standards, operational procedures and safety protocols to optimize performance and safety.
  • Delivered medications via oral, IV and intramuscular injections, monitoring responses to address new concerns.
  • Worked with interdisciplinary healthcare team to develop, implement and manage care plans, ensuring inclusion of patients' individual needs.
  • Documented all patient interactions and interventions in EPIC EMR, including physical and psychological assessments, care plans, treatment and observations.
  • Educated family members and caregivers on patient care instructions.
  • Provided skilled, timely and level-headed emergency response to critically-ill patients.
  • Performed triage on all incoming patients and determined severity of injuries and illnesses.
Skills
  • Physician consultations
  • Documentation and reporting
  • Interpersonal and written communication
  • Discharge planning coordination
  • Patient and family advocacy
  • EMR / EHR
  • Case Management
  • Strong clinical judgment
Education
05/2007North Arkansas CollegeCity, StateAssociate of Science: Nursing
06/2017Western Governors UniversityCity, StateBachelor of Science: Nursing
06/2020Western Governors UniversityCity, StateMaster of Science: Nursing
  • Member of Sigma Theta Tau International
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Resume Overview

School Attended

  • North Arkansas College
  • Western Governors University

Job Titles Held:

  • Utilization Review Nurse
  • RN Case Manager
  • Critical Care Registered Nurse
  • RN, Critical Care

Degrees

  • Associate of Science : Nursing
    Bachelor of Science : Nursing
    Master of Science : Nursing

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