Jessica Claire
Montgomery Street, San Francisco, CA 94105 (555) 432-1000,
Professional Summary

Dependable Utilization Review Nurse, promoting over 10 years expertise in healthcare industry. A Seasoned nursing professional offering proven clinical knowledge, strong interpersonal skill and extensive knowledge. Specializing in Case Management, medical-surgical, rehabilitation and home health care. Considered hardworking and driven. with excellent reputation for working with multidisciplinary teams to create care plans focused on patient's needs and goals.

  • Discharge planning coordination
  • Interpersonal and written communication
  • EMR / EHR
  • EPIC
  • MCG guidelines
  • Microsoft office
Work History
01/2018 to Current Utilization Review Registered Nurse Capital Health | Morrisville, PA,
  • Perform concurrent review, discharge planning and care coordination in accordance with approved departmental guidelines.
  • Perform admission reviews based on medical necessity utilizing Milliman Care Guidelines MCG and medical policies.
  • Facilitated workgroup meetings with interdisciplinary team such as physicians, pharmacist, social worker and other case managers to find effective solutions to members' issues.
  • Perform ongoing assessments to evaluate member's needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care.
  • Evaluate medical guidelines and benefit coverage to determine appropriateness of services within scope of plan. And make referrals for appropriate services
  • Utilize critical thinking skills and work in fast paced environment with minimal supervision.
  • Maintain accurate records of all members, adhere to company policy in safeguarding HIPPA and release of Patient health information PHI.
  • As team lead, assist other staff with UM process questions and help management in coordinating day to day activities.
  • Train new staff and act as mentor, providing resources and communicate company goals. In addition, inspire and motivate staff.
06/2012 to 02/2019 Registered Nurse, Medical-Surgical Unit Veterans Health Administration | Charlotte, NC,
  • Utilized EPIC to document data related to patient care such as medications, interventions and patient responses.
  • Managed patients recovering from medical or surgical procedures, including facilitating wound care, ostomy care, pressure ulcer prevention and pain management.
  • Managed care from admission to discharge, including patient assessments, care planning, health educations and discharging support to provide comprehensive care to over 5 patients daily.
  • Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process and management and lifestyle options.
  • Supervised clinician and non clinicians as charge nurse by delegating tasks to maintain continuum of care.
  • Precepted nurses, providing guidance on unit functions and individual roles, hospital policies and procedures and nursing best practices.
  • Provided direct patient care, stabilized patients and determined next course of action.
  • Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
11/2013 to 11/2016 Rehabilitation Registered Nurse Pacific Medical Centers | Ashland, OR,
  • Performed ongoing assessments to evaluate medical needs, working with multidisciplinary team to develop, initiate, manage and modify individualized plans of care.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities to prevent further disability.
  • Educated family members and caregivers on patient care instructions.
  • Administered different therapies and medications in line with physician orders and treatment plan.
12/2010 to 06/2012 Home Care Registered Nurse Lhc Group | Saint Augustine, FL,
  • Coordinated and collaborated with various multidisciplinary teams to coordinate care and promote patient safety and health.
  • Educated and supervised patients and family members regarding prevention strategies, self-care techniques and nursing care needs.
  • Administered medications and treatment to one patient per day and monitored responses while working with healthcare teams to adjust care plans.
  • Provided skilled, timely and level-headed emergency response to pediatric patients on ventilator
Expected in 05/2012 Bachelor of Science | Nursing The University Of Texas At Arlington, Arlington, TX GPA:
Expected in 05/2009 Associate of Science | Nursing Paris Junior College, Paris, TX GPA:
Expected in 03/2007 Diploma, Vocational Nursing | Nursing Tyler Junior College, Tyler, TX, GPA:
  • Certified Case Manager CCM 2020 to 2025
  • Milliman Care Guidelines Certification MCG 2018 to 2021
  • Certified Rehabilitation Registered Nurse - [2015 to 2020

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School Attended

  • The University Of Texas At Arlington
  • Paris Junior College
  • Tyler Junior College

Job Titles Held:

  • Utilization Review Registered Nurse
  • Registered Nurse, Medical-Surgical Unit
  • Rehabilitation Registered Nurse
  • Home Care Registered Nurse


  • Bachelor of Science
  • Associate of Science
  • Diploma, Vocational Nursing

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