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Utilization Management Nurse Resume Samples
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10+ years of experience
- Led the effort for analyzing and flowcharting the inpatient admission process.
- Established and implemented a more efficient process for providing patient care, ensuring timely and appropriate levels of care for the incoming patients. Also included palliative and Long Term care patients.
- Monitored and helped reduce avoidable readmissions where possible.
- As a team member, developed and instituted an education process for patients, including: preparation, education, and administration of multiple modes of recovery and rehab for Congestive Heart Failure (CHF) and Type II Diabetes. (i.e. Disease Management Approach)
- Created and set-up Intensive Care Unit evaluation criteria sets.
- Mentored staff on appropriate, efficient care procedures and methods.
0-5 years of experience
- Performed utilization review activities, including precertification, and retrospective reviews according to guidelines.
- Determined the medical necessity of requests by performing first level reviews using approved evidence based guidelines/criteria.
- Answered Utilization Management directed telephone calls; managing them in a professional and competent way.
- Referred cases to reviewing physician when the treatment request did not meet necessity per guidelines, or when guidelines were not available.
- Conducted and documented rate negotiations with out of network providers, utilizing appropriate reimbursement methodologies.
- Identified and referred potential cases to Disease Management and Case Management appropriately for proper follow up.
10+ years of experience
- Worked in different dedicated units within Aetna in a Managed Care Setting. Plan sponsors Included Marriott, Costco, TRS, and TRS Active Care.
- Performed pre certification review, admission reviews, concurrent review retro reviews using Milliman Care Guidelines and Aetna Clinical Policy Guidelines.
- Coordinated with facility case managers in discharge planning and transfer of patients to the appropriate level of care using knowledge of the dedicated units benefit plan. Assessed for unnecessary services and recommended other appropriate options.
- Identified services needed for members such as case management, disease management and behavioral health.
- Contributed to the start – up of the Marriott, Costco and TRS Active Care Units. Acted as resource to other team members.
0-5 years of experience
Provides utilization management services and support to health insurance members and health care providers, including but not limited inpatient admissions, continued stay reviews, service referrals and out-of-network referrals. Applies InterQual medical criteria, medical policy and benefit information in response to inpatient and home health precertification request.
- Consistently demonstrating excellence in quality assurance evaluations of work production.
- Taking initiative to work as a team with other nurses in meeting production goals.
- Collaborating with leadership and management in improvement measures for work processes.
- Received excellent anecdotal feedback from leadership leading to advancement of role.
0-5 years of experience
- Reviewed clinical information and records to perform utilization review assessing, monitoring and evaluating patient care for medical necessity for inpatient admissions utilizing internal [company name] criteria and Milliman Care Guidelines (MCG).
- Interfaced with medical facility multidisciplinary personnel to assess and direct discharge planning for patients.
- Eight years of 100% audits regarding documentation privacy, accuracy and timeliness in accordance with [company name] policy & procedures.
- High proficiency and team trainer for various [company name] proprietary computer programs and MS Office applications.
- [company name] Patient Management West Region nominated subject matter expert representative for Value Stream Mapping for process improvement for UMNC role.
0-5 years of experience
Communicate effectively with hospitals case managers, physicians, social services and discharge planners
- Telephonic prospective, concurrent and retrospective review using Interqual Criteria, CMS guidelines
- Assist in multi-disciplinary planning, educate co-workers on complex issues, processes and utilizing
- Prepare cases for Medical Director that does not meet criteria
0-5 years of experience
- Reviews Workers’ Compensation Utilization Management requests (prospective/concurrent/retrospective) for inpatient and outpatient services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer
- Certifies reviews that meet clinical review criteria/guidelines
- Maintains compliance with regulatory changes affecting utilization management
- Coordinates physician reviewer referral as needed and follows up timely to obtain and deliver those results
- Releases Workers’ Compensation Utilization Management determinations to claim stakeholders following established protocols
- Serves as a first level contact for customer complaint resolution
0-5 years of experience
Exceptional knowledge of utilization review.
- Well-versed with MS office and all the systems of healthcare like, CCMS, VITAL, QNXT, TSOL.
- Gave excellent healthcare benefits to every patient through utilization management service.
- Reviews documentation and interprets data obtain from systems to apply appropriate clinical criteria and policies in line with regulatory and accreditation requirement for members and providers.
0-5 years of experience
- Utilize the nursing process and McKesson software to approve authorization requests for members with Medicaid insurance coverage.
- Utilize McKesson software to process claim appeals.
- Develop work specific workflow processes and training documents.
- Run statistical data reports for the department.
- Team Lead for McKesson software implementation, management, and trouble shooting.
- Serve as team lead for resolution of authorization questions from member services in the absence of floor supervisor.
- Serve as a trainer for new employees on the use of McKesson software and the nursing workflow processes within the department.
- Work in conjunction with other members of the utilization management team to provide an indirect service to our members.
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Utilization Management Nurse
Last edited by: Gabriela Barcenas, CONTENT STRATEGIST -
Gabriela Barcenas
CONTENT STRATEGISTGabriela is a Certified Professional Resume Writer (CPRW) and career adviser. With 10 years of digital media experience and five years of resume writing expertise, her publication history includes fashion, education, travel, social justice, equitable design and career advice.
