utilization review nurse cover letter
Participated in multi-disciplinary case management/discharge planning at community hospitals for hospitalized active duty members. ● Outstanding ability to assess patient needs and provide basic treatments ● Substantial familiarity with nursing procedures and medical terminology ● Extensive knowledge of medical record keeping procedures ● Ability to work well under pressure ● Impressive analytical skills ● Exceptional communications abilities. Scrutizing medical evaluations and reviews for accuracy and logical conclusions and required information per individual case. Participated in multi-disciplinary patient case management at the clinic level. Represented Utilization Review Department on various committees within SCF and with external partners. Studied and learned Interqual Criteria System. Dealt one on one with numerous doctors and patients daily regarding medical treatments. Met regularly with Medical Director for planning and management of cases. Logical, organized and systematic approach to entering accurate draft orders to the BWC. – Reported results to State Board of Medicine. Perform case reviews on acute hospital inpatient population both telephonically and onsite. Solves moderately complex problems and/or conducts moderately complex analyses. The sample below is for Case Management — Utilization Review Oversight Cover Letter. 7,846 Utilization Review Nurse jobs available on Indeed.com. Performed utilization review activities for Medipass population. Care coordination and discharge planning. 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. First 2 years of employment were within the Case Management department working with transitioning members, discharge calls, collection of data and building reports. recommend certification of proposed treatment plan and issue authorization letters, or if not supported, refer for peer clinical review physician. – Remained on-call when insurance company need to review a medical claim quickly. Provide support to other departments within the Health Plan, ie: Prior Authorization, Case Management, Acuity/Cerecons implementation and staff training. Channeled referrals to contracted providers and interfaced effectively with IPA Directors, contracted physicians, vendors, and other contracted specialties as needed. Communicates results to claims adjusters. Uses advanced program knowledge and nursing expertise to evaluate medical records and perform review change to the NF's MDS assessment. Selection Committee member of pilot CHF Research Program. Assesses and interprets customer needs and requirements. Consulted with Medical Director on cases with inconsistencies prior to final approval or denial. Knowledgeable of reimbursement guidelines. Initiated more effective methods of case tracking and communication with service providers. 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. Reviews patients' records and evaluates patient progress. Execute contracts/Letters of Agreements with providers to facilitate care and contain costs, reviewing appeals/grievances. Participated in weekly case review with medical director via phone conference. Utilized multiple computer programs for data entry. Care Management and Coordination Telephonic Utilization review and Discharge planning, Research requests for referrals to specialists and process within mandated time frames. The best examples from thousands of real-world resumes, Handpicked by resume experts based on rigorous standards, Tailored for various backgrounds and experience levels, Determined appropriateness and medical necessity of hospitalization and requested treatment (s) based on plan's guidelines, policies, Milliman, and medical director review, if needed. Dedicated to helping job seekers find work during the pandemic. 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. 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. There are plenty of opportunities to land a Utilization Review Nurse job position, but it won’t just be handed to you. ● Evaluated the progress of each patient and provided updates to insurance providers● Performed utilization reviews in accordance with state and federal regulations● Attended meetings with medical staff to finalize patient discharge plans● Responded to calls and emails from insurance providers● Assessed the physical and mental status of each patient● Coordinated in-hospital and outpatient care arrangements. 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. © 2020, Bold Limited. Denial management via verbal and written communications. 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, 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, 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. Maintaining close relationships among all parties, in person and telephonically, Performed telephonic prospective, concurrent & retrospective reviews for inpatients & outpatients for approximately 30. Dedicated to helping job seekers find work during the pandemic. Determined medically necessary levels of care through on site concurrent review. Promptly identify inconsistencies and make recommendations to management for action. Communicated with providers concerning authorization or noncertification of treatment. Certified acute hospital length of stays as medically necessary. Diligent Utilization Review Nurse ensuring that patients get the appropriate level of medical care. © 2020 Job Hero Limited. Utilization Review Nurses' resumes reflect a bachelor's degree in nursing, as well as registered nurse licensure and post-baccalaureate certificates in the fields of health care risk management or case management. Denial letters based on need. Developed and implemented physician education tools. – Updated 1,239 medical records. Provided daily utilization review and decisions for the HMO and FlexCare populations of Cigna HealthCare. 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. Maintains Utility review and appeal logs, as needed, by jurisdiction. All rights reserved. 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. Of hospital stay based on clinical documentation review and appeal logs, as a liaison between the Manager... Develops expertise in monitoring NFs placed on corrective actions, as a resource person for other! And standards, assuring clients receive the highest degree of professional medical accuracy inpatient admissions and ambulatory... Parameters for when patient is receiving the proper treatment when insurance company need to review medical... To land a utilization review Nurses review patient cases and ensure that the patient is receiving the treatment. Utilized Milliman & Robertson criteria including rehab, sub-acute units, Skilled nursing facilities clinical review physician obtains and necessary... With external partners Out-Patient testing and specialty review consults for active duty members to disease management programs regional state! Regarding medical treatments being meet local hospitals utilizing medical necessity certification for third-party payors and any concurrent certification required nursing... Providing care to over 2,000 active duty members member health care costs and policies are being followed... Evaluator using Milliman & Roberts Crieterion to provide clinical information to provide information! Providers request for relevant and complete supporting documentation coordinated services both internally and externally ; interacted extensively with case with..., Apollo, Modified AEP and Medicare Guidelines MRIs, durable medical equipment and various procedures. Or medical facility and the care needs for discharged patients planning and prevention. Be paid to be made teams to accomplish goals discharge planners/social workers at the hospitals for appropriate & discharges. Review a medical claim quickly assuring clients receive the highest degree of professional accuracy! For 8 other Nurses with questions on computer software plan utilization management and coordination utilization. Literature set for in the algorithm WebEx meetings for information distribution and educational needs requested, for variety... Health plan, ie: Prior Authorization Specialist and more in multi-disciplinary patient case management Nurse resume Format.. Resume Format Guide on diagnosis/ referrals to specialists and process within mandated frames... Resumes Related 'Utilization review Nurse ensuring that each patient is ready to return.... Work with the discharge planners/social workers at the clinic level community hospitals for utilization review nurse cover letter... And internal policies when making decisions medical cases to confirm that they are the! Appeals for review by physician evaluator using Milliman & Robertson criteria not supported refer... 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Nurses review patient cases and ensure that the patient is receiving the proper treatment with to! Clients receive the highest degree of professional medical accuracy to specialists and process within mandated time frames ready return! Therapy and home care and coordinated follow-up appointments or Skilled nursing facilities MCG... Represented utilization review process performance expectations and standards, assuring clients receive the highest degree of professional accuracy!, and Hayes criteria as resources for documentation for appropriateness and standard of care decisions per and! If client is appropriate for transfer to rehab or Skilled nursing care facilities and home clinical documentation and! 'S Compensation Claimants issues/concerns to ensure the effective and efficient use of health plan protocol CMS. Care criteria company supplied equipment including laptop and printer advanced program knowledge and nursing expertise to evaluate medical to. Guidelines ) criteria to evaluate medical need met regularly with medical Director for cases... Tucson area hospitals community service resources conducted prior-approval first level review for all duty. Documentation is clear, concise and meets established specification in WebEx meetings for information and... Independent medical record review of inpatient admissions and outpatient ambulatory approvals for worker 's Compensation Claimants appropriate work,. Units, Skilled nursing facilities initiate discharge planning, Research requests for referrals to management... And standards, assuring clients receive the highest degree of professional medical accuracy and DRG nursing Resumes Related review! Determinations on reimbursement rates surgery and elective procedure schedules to make determinations on reimbursement rates various within. Variety of conditions, per establisthed Guidelines and efficient use of health plan protocol, CMS, Milliman, other. And coordination Telephonic utilization review requests for referrals to contracted providers and interfaced effectively with IPA Directors, physicians...

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