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0-5 years of experience
Determined appropriateness and medical necessity of hospitalization and requested treatment (s) based on plan’s guidelines, policies, Milliman, and medical director review, if needed. Also, includes observation status
- Responsible for requesting clinical information for concurrent review with strict adherence to URAQ guidelines
- Responsible for presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging any peer-to-peer reviews, if requested by hospitalist, attending, or primary care physician
- Assisted and/or provided facility interdisciplinary teams benefit information for in network providers/facilities, DME, home healthcare, acute, sub-acute rehab, skilled nursing facilities, and out-of-network benefits, if needed
- Communicated frequently with assigned case managers for unplanned admissions, inpatient status, and discharge plan with orders
- Collaborated with assigned case manager to identify members frequent hospital readmissions
- Participated in weekly UM Grand Rounds with plan liaison, medical director, URNs and Alere oncology medical director
0-5 years of experience
Reviewed high volume case load of patient charts to determine medical necessity based on nursing knowledge and state mandated guidelines
- Dealt one on one with numerous doctors and patients daily regarding medical treatments.
- Answered a busy phone line to educate and explain treatments ordered
- Spoke with insurance agents regarding ICD-9 and CPT codes
- Collected documentation from numerous providers to add to patient medical history chart
- Performed duties in accordance with well-established rules, procedures, regulations, principles and operations covering patient medical records, their required contents, establishment and maintenance of special registries, documentation of incidents, and diagnostic coding requirements and procedures.
- Utilized knowledge of an extensive body of well-established medical records procedures, rules, processes, company and legal policy for multiple states and areas of responsibility; to include establishing, coding, maintaining, and disposing of patient medical records.
0-5 years of experience
Managed comprehensive chart audits for Additional Documentation Requirements (ADR) for Fiscal intermediary review, adverse events review, and error report review for process improvement
- Conducted OASIS Review to assess appropriateness of documentation for 485 document preparation and ICD-9 Diagnosis Coding
- Verified compliance with Agency Policy and Procedure, State, JCAHO, and Hem 11 Guidelines
- Managed various insurance audit reviews and subpoena audits for payer inquires
- Conducted Medicaid/MediCal care management pre-authorization an treatment authorization requests
- Conducted Peer Review preparation, facilitated peer review meetings, and assessed data collection of review findings
- Trained and oriented new staff members in learning OASIS documentation procedures
- Attended conferences to refine skills for OASIS correlation with ICD-9 coding
0-5 years of experience
Evaluated and authorized medical necessity of services
- Prepared reports and documentation for monthly board meetings
- Prepared and submitted monthly IPA reports for delegation audits
- Provided supervision in operating an IPA/POD
- Monitored and insured productivity and performance
0-5 years of experience
Medicaid Managed Care
- Reviewed NJ Choice and PCA tool for members to decipher medical necessity
- Analyzed member records to ensure compliance with government and insurance company reimbursement policies
- Determining member review dates according to established diagnostic criteria
- Maintained utilization review logs as needed and created reviews to send to medical director
- Perform administrative duties; create spreadsheets to log daily activities and other documents as assigned
0-5 years of experience
Perform, monitor, and determine medical necessity reviews on inpatient and outpatient healthcare services ensuring health care services being performed in the appropriate setting
- Ensure effective care being delivered through the use of nationally recognized criteria
- Analyze appropriate medical benefits are applied to services reviewed for medical necessity
- Serve as liaison between members, providers, benefits and customer service team
- Collaborate with Medical Director and Director of Medical Management in reviewing clinically complex patients
- Refer cases as necessary to case management to assist in management of catastrophic patients
- Identify, initiate and perform discharge planning on clinically complex patients effectively decreasing readmissions
0-5 years of experience
To ensure the effective and efficient use of health care services.
- Provided hospital pre-certification and concurrent medical record reviews to determine appropriateness of admissions, procedures and length of stays.
- Provided non-inpatient case reviews to determine the medical necessity and appropriateness of treatment plans, ratings and Out-Patient Services.
- Collaborated with multidisciplinary teams.
- Reviewed medical records for ICD 9, CPT and DRG. Certified acute hospital length of stays as medically necessary.
- Maintained statistical records and quarterly reports as required.
- Represented Utilization Review Department on various committees within SCF and with external partners.
0-5 years of experience
Family Practice staff nurse for 4 physicians providing care to over 2,000 active duty personnel and their families. Some areas of responsibility included the management of immunizations; routine care; medication refills; referral to specialty clinics; assisting with minor procedures; scheduling; depo-medrol clinic; blood draws and patient education.
- Obtained required credentials as a Certified Professional in Utilization Review, developed the program, provided training to physicians and other clinic staff then implemented Utilization Review and Case Management programs for the clinic.
- Instrumental in the successful transition of the military healthcare system for active duty personnel from Supplemental Medicine paid by active duty commands to the new TriCare Healthcare System. Liaison with new network providers and hospitals to ensure correct contact information available to them to facilitate Utilization Review and timely processing of claims for payment.
- Conducted prior-approval first level review for all requested out-patient testing and specialty review consults for active duty personnel.
- Conducted stay reviews for all active duty personnel hospitalized in the community and facilitated transfer to military hospitals when indicated.
- Participated in multi-disciplinary patient case management at the clinic level. Participated in multi-disciplinary case management/discharge planning at community hospitals for hospitalized active duty members. Facilitated acquisition of needed durable medical equipment and supplies for home care and coordinated follow-up appointments.
- Developed standard of practice and competencies for telephone triage and supervised assigned staff.
0-5 years of experience
Determined medically necessary levels of care through on site concurrent review.
- Authorized appropriate and cost effective level of services.
- Proactively educated physicians and patient/caregivers regarding vendor and community service resources.
- Coordinated in-home services post hospital discharge.
- Initiated more effective methods of case tracking and communication with service providers.
- Selection Committee member of pilot CHF Research Program.
6-10 years of experience
Provided comprehensive Utilization Review, prospectively, concurrently or retrospectively utilizing cost containment strategies
- Determined whether all aspects of patient care, at every level, to be medically necessary and appropriate.
- Review physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria. recommend certification of proposed treatment plan and issue authorization letters, or if not supported, refer for peer clinical review physician.
- Compliance with established utilization review process performance expectations and standards, assuring clients receive the highest degree of professional medical accuracy.
- Maintaining close relationships among all parties, in person and telephonically
0-5 years of experience
- Performed telephonic prospective, concurrent & retrospective reviews for inpatients & outpatients for approximately 30
- Prepared potential non-certifications & appeals for review by physician evaluator using Milliman & Robertson criteria.
- Communicated with providers concerning authorization or noncertification of treatment.
- Used utilization review application of DOS.
- Acted as a resource person for 8 other nurses with questions on computer software.
0-5 years of experience
Performed offsite utilization review and case management
- Provided approval for emergency and scheduled hospital admissions based on the medical necessity and standard criteria
- Identified and coordinated discharge needs and transfers to a lower level of care
- Approved home needs post-discharge such as home health aids, wheelchairs and IV infusions.
0-5 years of experience
Charge Nurse on an adult acute and subacute unit for crisis management services
- Provided quality care for acute and chronically homeless in long term structured and substance abuse units
- Completed initial admission assessments and treatment plans
- Observed patients for side effects and behavioral changes
- Participated in daily treatment team meetings to discuss discharge and aftercare planning
- Monitor and schedule additional medical services
- Conducted stay reviews and participated in staff education related to utilization management
0-5 years of experience
Two plus years experience as Recovery Audit Contractor (RAC) auditor in comprehensive medical review of Skilled Nursing Facilities (SNF), Long Term Care Hospitals (LTCH), Short Term Hospitals (STCH) and Outpatient Therapy
- Team member for development of LTCH RAC audit review processes
- Applied Medicare Regulations in making clinical determinations for decision making in the review process
- Use of Millimen and Interqual criteria programs
- Knowledge of HIPAA standards and CMS security requirements
- Used clinical nursing judgment in the review process based on clinical experience
- Provided detailed documentation of medical review findings in all claims reviewed
- Utilized knowledge of medical terminology, ICD-9 codes, HCPCS, DRG’s and Current Procedural Terminology (CPT) codes
- Maintained quality work in all review types ranking 95-100% in monthly QA scores
0-5 years of experience
- Processed radiology requests on behalf of various contracted managed care plans via telephone queue line, fax and web portal while maintaining departmental and corporate productivity standards
- Researched rejected claim inquiries for internal and external customers
- Processed denial letters with notification of contract specific EOB and disclaimers
10+ years of experience
- Conducted initial, concurrent and retrospective review of inpatient admissions and outpatient ambulatory approvals for Worker’s Compensation Claimants.
- Reviewed medical records to determine approvals or denials for length of hospital stay based on Interqual criteria.
- Determined approval or denial for durable medical equipment, physical/occupational therapy and home health care.
- Conducted telephonic reviews using Interqual criteria to support the need for admission and/or extension of inpatient stay.
- Maintained and documented case files from inception to closure.
- Consulted with Medical Director on cases with inconsistencies prior to final approval or denial.
- Used Interqual, Official Disability Guidelines (ODG), American College of Occupational and Environmental Medicine Guidelines (ACOEM), State of Massachusetts Guidelines, Crawford & Company Internal Medical Policy Bulletin, Broadspire’s Physician Advisory Criteria and Physical Medicine Criteria.
0-5 years of experience
Reviewed and evaluated medical records for in-patient admissions to determine if required documentation was present. Conducted ongoing reviews and coordinated discharge care with attending physicians to ensure continuity of patient care.
- Identified and coordinated services both internally and externally; interacted extensively with case managers and physicians to determine follow-up care needs for discharged patients.
- Worked with insurance companies to determine allowable coverage; reviewed surgery and elective procedure schedules to make determinations on reimbursement rates.
- Followed patients from admission to discharge, making sure the current level of care was optimal; communicated necessary moves from acute care to less intensive setting at appropriate intervals.
- Balanced the business and revenue needs of the organization with the patient care requirements and often advocated for additional reimbursements or coverage to allow patient to receive needed continuum of care.
- Reinforced policies, evaluate patient situations and weighed patients individual needs against the insurance coverage details; contributed to making final decisions on treatment, medications, surgeries and re-admissions.
0-5 years of experience
Respond to calls and faxes to preauthorize Medicaid surgeries, MRIs, durable medical equipment and various medical procedures.
- Certified in MCG (Milliman Care Guidelines) criteria to evaluate medical need.
- Worked with Amisys, TruCare and RightFax software.
- Created training documents for future new employees.
- Worked in coordination with several other teams to accomplish goals.
0-5 years of experience
Full-time as CDS 2 years then split hours between both jobs
- Concurrent review and analysis of EMR documentation
- Collaboration with physicians to clarify diagnoses, initiate queries, improve documentation. Developed and implemented physician education tools.
- Working knowledge of DRG/ICD-9 codes and reference materials
0-5 years of experience
Processed preauthorization requests received via telephone, fax or web
- Conducted initial medical review to determine medical necessity of elective outpatient comprehensive imaging requests
- Issued approvals for studies that meet the specified guidelines or forwarded studies that did not meet the guidelines to the Medical Director
- Participated in on-going training programs to ensure quality performance and compliance with guidelines
0-5 years of experience
Performs utilization review activities and reviews according to guidelines
- Review cases by applying appropriate medical criteria
- Supports review by using utilizing state or state recommended guidelines
- Ensures that documentation is clear, concise and meets established specification. Documentation must be grammatically correct with proper punctuation, capitalization and grammar.
- Communicates with team to review issues/concerns to ensure that there is appropriate work flow, communication and documentation on each file.
- Works and completes partial prep, chronologies and full prep as assigned
0-5 years of experience
Administered utilization review and management of referrals for over 400 Warrior in Transition Unit Soldiers and all Solider Readiness Center deploy/ redeploy Soldiers
- Reviewed and developed process improvements to increase efficiency and accuracy in the referral management process and ensured compliance with the Department of the Army MEDCOM military treatment facility Access Standards for Active Duty Service Members
- Coordinated ongoing training to CRC, WTU/SRC staff, Nurse Case Managers, Medical providers, and Evans Army Community Hospital staff while also serving as a preceptor, trainer and mentor for new UR nurses and CRC staff
- Oversaw appropriate management of command approval authority by screening referrals and ADSM request for proper medical outsourcing needs, anticipated cost/benefits and/or need to defer to DCCS for additional review
0-5 years of experience
Coordinate discharge planning with the patients, their families, and the healthcare team
- Work with the doctors, and other interdisciplinary health team to ensure patient’s safe discharge
- Coordinates with the insurance companies to ensure that medical services provided are covered
- Assist with patients education, and provides them with resource information
- Lead interdisciplinary daily discharge rounds of all patients on assigned unit
- Identify high risk patients and work together with other interdisciplinary healthcare team to ensure that patients are not being delayed for their services
- Perform utilization reviews for all commercial insurance and all Medicare patients assigned, to ensure that patients meet admission criteria to continue to be in an acute care facility
0-5 years of experience
Made recommendations for approval for utilization review requests for treatment given the request fell within evidence-based medical literature set for in the algorithm.
- Provided recommendations for denial or modification for utilization review requests for treatment when the request fell outside evidence based guidelines set forth in the algorithm.
- Participated in peer to peer physician reviews of utilization review requests that had previously been denied or modified based on provided medical reporting
- Rendered accurate decisions and demonstrated great writing abilities
- Consistently noted to achieve a very high level of productivity
0-5 years of experience
Provides authorizations and/or denials based on clinical documentation review and medical necessity.
- This positions focus will involve and support Manage Long Term Care program, homecare and personal care program activities to include pre-authorizations of and concurrent review of medically necessary services.
- Collaborates closely with the Medical Director for complex cases.
- Develops expertise in a managed care plan Utilization Management process.
- Assesses and interprets customer needs and requirements
- Identifies solutions to non-standard requests and problems.
- Solves moderately complex problems and/or conducts moderately complex analyses.
0-5 years of experience
Perform case reviews on acute hospital inpatient population both telephonically and onsite
- Apply Interqual criteria
- Present oral case presentations daily to Physician Reviewer
- Perform discharge planning, including home health, nursing home placement, rehabilitation, and assistance with community resources
- Review clinical information for medical necessity and appropriate level-of-care for patients admitted to the hospital
- Review clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate
- Initiate discharge planning and readmission prevention plan when applicable.
0-5 years of experience
Responsible for completion of pre certification for third-party payors and any concurrent certification required.
- Ensured adequate financial reimbursements.
- Learned ICD 9 coding system.
- Studied and learned Interqual Criteria System.
0-5 years of experience
Analyze patient records to determine legitimacy of admission treatment and length of stay in healthcare facility to comply with government and insurance company reimbursement policies
- Abstract data from records
- Provide case summaries to insurance companies
- Communicate with insurance companies and informing them of clients current progress and future treatment plan with the goal of obtaining further authorization
- Complete follow through for disposition of cases- MD reviews, chart reviews, audits, case management referrals
- Determine patient review dates according to established diagnostic criteria
- Assist review committee in planning and holding federally mandated quality assurance reviews
0-5 years of experience
Working with a team of Case Mangers, Utilization Review Nurses and Physicians on a daily basis, reviewing medical criteria for continuation of care or discharge planning.
- Working under the guidelines of Acute Care vs Skilled Nursing Rehab insuring members are meeting the criteria for proper level of care to meet their current Rehab needs.
- Collaborating on a daily basis with Case managers both at Carefirst and participating facilities to insure member meet criteria for continuation of care
- Contacting members both inpatient and after discharge to addressing any needs, and refereing to various health care services to include PCMH program for continuity of care once discharge home.
- Working with medical director when member requires transfers, or continue length of stay to insure member health care needs as being meet.
- Entering information via computer system approving medical criteria to insure payment of claims in a timely manner.
- Though knowledge of medical admission guideline to include Milliman, Apollo, Modified AEP and Medicare Guidelines.
0-5 years of experience
Work with Medical Director in determining if hospitalization is needed and if client is appropriate for transfer to Rehab or Skilled Nursing Facilities
- Review charts of clients that are in Tucson area Hospitals
- Work with the discharge planners/social workers at the hospitals for appropriate & safe discharges.
- Oversight of patient care and medical needs via AHCCS standards
- Ensure patient transfers are appropriately handled by facilities and their staff
- Coordinate all discharge planning activities
- Evaluate charts of patients to make sure they meet inpatient criteria per facility standards
10+ years of experience
Responsible for the coordination of managed care patients, tracking appropriate utilization of services.
- Knowledgeable of reimbursement guidelines.
- Continuously assess the clinical data to make sure the visits are medically necessary and meet managed care criteria.
- Act as a resource to new and current staff members as well as outside providers to insure appropriate utilization.
- Review initial admission information to provide clinical information to providers for utilization and payment.
6-10 years of experience
Medical records review and determination of days based on Milliman Care Guidelines. Covering UMC and multiple skilled nursing facilities.
- Denial letters based on need. Care coordination and discharge planning.
- Education and training of new and current employees in Acuity and frequently utilized applications specific to the Health Plan
- Provide support to other departments within the Health Plan, ie: Prior Authorization, Case Management, Acuity/Cerecons implementation and staff training.
- First 2 years of employment were within the Case Management department working with transitioning members, discharge calls, collection of data and building reports.
6-10 years of experience
Medical records review and determination of days based on Milliman Care Guidelines. Covering UMC and multiple skilled nursing facilities.
- Denial letters based on need. Care coordination and discharge planning.
- Education and training of new and current employees in Acuity and frequently utilized applications specific to the Health Plan
- Provide support to other departments within the Health Plan, ie: Prior Authorization, Case Management, Acuity/Cerecons implementation and staff training.
- First 2 years of employment were within the Case Management department working with transitioning members, discharge calls, collection of data and building reports.
0-5 years of experience
Independent medical record review of patient information to validate medical necessity for correct billing
- Review patient specific information to ensure medical necessity for requested durable medical equipment, home health services and supplies using InterQual criteria and/or state regulated guidelines
- Demonstrate critical thinking, interpersonal oral and written communication skills to support review findings
- Ensure consistent application of the utilization review process for all functioning components
- Verify eligibility and review past utilization history
- Participate in special projects and monthly meetings
- Followed compliance rules and regulations for accurate billing of durable medical equipment, home health services and supplies
- Managed workload to ensure timely processing per state and federal mandates.
0-5 years of experience
- Utilization Review Nurse for Nexus Medical Consulting.
- Reviewed individual medical cases to confirm that they are getting the most appropriate care.
- Inspected claims to determine whether or not they should be paid.
- Weighed patient situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment.
0-5 years of experience
Utilization Management and Case Management Nurse
- Used Interqual Criteria and internal policies when making decisions.
- Worked with HMO and PPO product lines.
- Denial management via verbal and written communications.
- Assisted with the Appeals and Grievance process. Communicated with the medical director as needed to expedite the decision making process.
0-5 years of experience
- Provided daily utilization review and decisions for the HMO and FlexCare populations of Cigna HealthCare.
- Utilized Milliman & Roberts Crieterion to provide appropriate level of care decisions.
- Assisted hospital case managers with discharge planning to appropriate post-hospital environments including rehab, sub-acute units, skilled nursing care facilities and home.
0-5 years of experience
Act as a liaison between the case manager and the provider/injured worker and all other parties to the claim.
- Investigating a claim. Ensuring correct and necessary information on the request.
- Utilizing the nursing process, to determine the appropriateness of treatment requested, for a variety of conditions, per establisthed guidelines.
- Entering Medical Director Reviews, claim reactivations.
- Scrutizing medical evaluations and reviews for accuracy and logical conclusions and required information per individual case.
- Understanding of appeals process. Logical, organized and systematic approach to entering accurate draft orders to the BWC.
- Working in a team atmosphere. Collaborating and communicating with physicians, lawyers, co-workers and support members to facilitate appropriate processing of appeals, peer review selection and appeal process.
10+ years of experience
Care Management and Coordination Telephonic Utilization review and Discharge planning
- Provide acute care concurrent review and acute rehab reviews.
- Demonstrated knowledge of Millman and Interqual criteria.
- Coordinate post-acute care needs for member with Medical Director.
- Perform discharge planning including SNF, Acute rehab, LTAC, Sub acute placements and home care authorizations.
- Process and authorize DME needs.
- Assist with orientation of staff.
0-5 years of experience
Research requests for referrals to specialists and process within mandated time frames
- Approve requests or defer to physician or insurance company for review
- Review surgical/procedure requests for medical necessity using InterQual
- Serves as a resource to physicians, staff and patients in regards to the utilization review process
- Maintain current knowledge of plan benefits, exclusions, eligibility an co-payment or co-insurance information for insured members as well as vast knowledge of Medicare guidelines
- Accept and direct multiple phone calls via queue line
- Process denial letters
10+ years of experience
Concurrent review and authorization of inpatient/hospital services using nationally recognized guidelines(MCG- Milliman Care Guidelines), assigning lengths of stay, determining medical necessity and individual patient health needs and availability of services and resources based in accordance to benefit provisions of subscriber’s health plan. Discharge planning, case management, care management, conducting disease management programs and appropriate referrals to disease management programs.
- Registration, review and authorization of inpatient hospital and skilled nursing stays using daily review information consisting of treatments and delivery of care based on medical necessity.
- Assigning length of stay based on diagnosis/ICD-9, ICD-10, procedures and review necessity for ongoing hospital and skilled nursing stays, Inpatient pre-certification, concurrent and retrospective review of delivery of care and treatment in hospital setting.
- Identify, evaluate, and initiate case management on patients based on diagnosis/ referrals to Case management/Disease Management Programs.
- Perform telephonic case management on discharged patients to assess needs in the home, follow up with physicians and trouble shoot in order to deliver appropriate and timely care and prevent readmissions.
- Execute contracts/Letters of Agreements with providers to facilitate care and contain costs, reviewing appeals/grievances.
- Experienced in working in a managed care environment.
0-5 years of experience
Work from home based position in Pensacola area.
- Performed utilization review activities for Medipass population
- Onsite review of medical records at local hospitals utilizing medical necessity criteria for stay.
- Home based position using company supplied equipment including laptop and printer
- Utilized multiple computer programs for data entry.
- Participated in weekly case review with medical director via phone conference.
- Participated in WebEx meetings for information distribution and educational needs.
- Acted as team lead for remote home based employees providing support and answer questions as appropriate.
- Acted as fill in manager during vacations and absences of manager
0-5 years of experience
Review providers request for relevant and complete supporting documentation
- Involved in every aspect of the utilization process of cardiology/Oncology Treatment regiments including authorization Requests, referrals, approvals and case preparation for medical review, request and review of medical records
- Verifying accuracy of codes and services
- Comply with current URAC standards
- Establish and maintain professional relationships with providers office and staff to ensure operational flow of authorizations and referrals
- Comply with HIPPA requirements
0-5 years of experience
Responsible for online referral management requests for specialty care, elective surgeries, Treatment plans and diagnostic studies in accordance with commercial and senior health plans with emphasis on timeline criteria.
- Utilization of health plan protocol, CMS, Milliman, and Hayes Criteria as resources for documentation for appropriateness and standard of care.
- Met regularly with Medical Director for planning and management of cases.
- Channeled referrals to contracted providers and interfaced effectively with IPA Directors, contracted physicians, vendors, and other contracted specialties as needed.
- Understands health plan benefits and contractual information
0-5 years of experience
Advanced nursing work to assure the reconsideration and corrective action processes for Medicaid Nursing Facilities in accordance to state rules, regulations, and written policies and procedures.
- Uses advanced program knowledge and nursing expertise to evaluate medical records and perform review change to the NF’s MDS assessment.
- Nursing expertise in monitoring NFs placed on corrective actions, as a result of inaccurate MDS assessments.
- Assists with the planning, development and implementation of policies, procedures and training materials; and provides NF staff and UR nurse reviews with ongoing education.
- Promptly identify inconsistencies and make recommendations to management for action.
- Collaborate with regional and state office staff related to any sanctions or other actions to be taken regarding contract non-compliance.
- Establish and maintain effective working relationships and communication with HHSC staff and staff from other agencies and organizations; appropriately interact with NFs and provide timely responses to requests and inquiries.
0-5 years of experience
Enter required notification data and order documentation with accurately within time lines
- Respond to incoming calls within processing times and utilize pre-certification guidelines
- Review surgical cases according to medical necessity using Medicare and inter-qualification guidelines
- Refer pre-determinations to Medical Director as appropriate
- Licensed Practical Nurse
0-5 years of experience
Provide clinical support for TPA and Self-funded Insurance Plans
- Review medical record documentation to determine medical necessity
- Apply and document Milliman criteria to support precertification
- Reference Plan documents for each client
- Refer cases for external initial Physician review and Appeal
- Effectively communicate with Clients, Facilities, Physician Offices and Clinical staff
0-5 years of experience
Utilization review of MA Workmen’s Compensation claims
- Performs utilization review in accordance with all state mandated regulations.
- Maintains compliancy with regulation changes affecting utilization management. Reviews patients’ records and evaluates patient progress.
- Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct
- Ensures appropriate and cost-effective healthcare services to patients.
- Documents review information in computer. Communicates results to claims adjusters. Enters billing information for services. Prepares information for notification letters for providers and employees.
- Receives and processes requests for appeal of denials. Responds to complaints per UR guidelines. Maintains Utility review and appeal logs, as needed, by jurisdiction.
0-5 years of experience
Provide UR and discharge planning on a variety of inpatient units including, Behavioral Health, Addictions, Pediatrics, Antepartum and med-surg
- Maintain communications with the payer at the time of admission and throughout the hospitalization to ensure necessary approvals for care and clarification of benefits
- Monitor for appropriateness of admission, stay and readiness for discharge based on criteria as evidence by appropriate documentation and Interqual
- Complete retrospective reviews for Behavior Medicine Units to obtain approval of care
- Processed paperwork for active duty military personnel, their dependents and retirees for admission to VHC’s addictions and rehabilitation program utilizing their Tricare benefit
6-10 years of experience
- Current Team leader over 5 co-workers, daily assignments, and assist with supervisor delegation of duties
- Case management 20 to 30 inpatient hospital stays
- Discharge planning and utilization of Milliman and Roberts software
- Work on weekend team, post hospital discharge calls
- Transition patient care to lesser setting SNF, LTACH, home care
- Work directly with hospital case management to coordinate patient care
- Special assignments such as employee management and weekend/discharge appeals programs
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Utilization Review 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.
