5 Utilization Review Nurse Resume Objective Examples

555-555-5555 | email@email.com | Baton Rouge, LA

Resume Objective

Dedicated utilization review nurse with three years of experience assessing medical necessity, ensuring compliance with healthcare regulations, and optimizing patient care while controlling costs. Skilled in case review, insurance authorizations, and collaborative care planning. Seeking to leverage expertise in clinical assessment and utilization management to support efficiency and quality outcomes in a healthcare organization.

Work Experience

Utilization Review Nurse

Baton Rouge Healthcare System | Baton Rouge, LA | Jan 2021 – Present

• Conduct comprehensive clinical reviews to assess the necessity and appropriateness of medical treatments, ensuring compliance with insurance guidelines and regulatory standards.
• Collaborate with physicians, case managers, and insurance providers to facilitate pre-certifications, approvals, and denials based on medical necessity criteria.
• Utilize InterQual and MCG guidelines to determine the appropriateness of hospital admissions, procedures, and ongoing care.
• Prepare and submit appeals for denied claims, ensuring accuracy in documentation and justifications for medical services.
• Monitor length of stay (LOS) and discharge planning, advocating for cost-effective, quality patient care.
• Provide education and guidance to nursing staff and case managers on utilization review processes and best practices.

Registered Nurse – Medical-Surgical Unit

Bellefleur Hospital | Baton Rouge, LA | Jun 2019 – Dec 2020

• Delivered direct patient care to diverse patient populations, monitoring patient progress and implementing physician-ordered treatments.
• Assisted in case management and discharge planning, ensuring continuity of care post-hospitalization.
• Maintained compliance with HIPAA, JCAHO, and hospital protocols while documenting patient information accurately.
• Worked with interdisciplinary teams to assess patient needs, contributing to utilization review and resource management.

Skills

• Utilization Review & Case Management
• InterQual & MCG Guidelines
• Pre-authorization & Appeals Processing
• Insurance & Regulatory Compliance (Medicare, Medicaid, Commercial Plans)
• Clinical Documentation & Medical Necessity Reviews
• Collaboration with Physicians & Insurance Providers
• Electronic Health Records (Epic, Meditech, Cerner)
• Patient Advocacy & Discharge Planning

Education

Bachelor of Science in Nursing (BSN)

Louisiana Tech University | 2017