Medical records review and determination of days based on Milliman Care Guidelines. Assists in cost containment through the appropriate ordering and conserving of supplies and equipment. Worked in coordination with several other teams to accomplish goals. 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. Provided hospital pre-certification and concurrent medical record reviews to determine appropriateness of admissions, procedures and length of stays. Studied and learned Interqual Criteria System. Utilized Milliman & Roberts Crieterion to provide appropriate level of care decisions. Maintained confidentially and compliance adhering to Health Insurance Portability and Accountability Act (HIPPA) guidelines when reviewing medical documentation. Maintains compliancy with regulation changes affecting utilization management. 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, Review medical record documentation to determine medical necessity, Apply and document Milliman criteria to support precertification, Refer cases for external initial Physician review and Appeal, Effectively communicate with Clients, Facilities, Physician Offices and Clinical staff. Works with medical directors in interpreting appropriateness of care and accurate claims payment. Strong analytical skills, capable of assessing conditions and implementing appropriate intervention. Performs concurrent and retrospective review to establish criteria. 20+ utilization review resume samples to customize for your own use. Utilizes nursing experience and judgment in addition to the client-specific guidelines when determining medical necessity and quality check dates. Enter required notification data and order documentation with accurately within time lines, Provide clinical support for TPA and Self-funded Insurance Plans, Utilization review of MA Workmen's Compensation claims, Provide UR and discharge planning on a variety of inpatient units including, Behavioral Health, Addictions, Pediatrics, Antepartum and med-surg. 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. Accountable for Utilization and Quality Management of examination levels, technology, and medication use efficiency, while simultaneously improving patient outcomes. To help you get started, here’s a sample cover letter for a registered nurse. find here samples that will help you to learn how to create your template. Certified in MCG (Milliman Care Guidelines) criteria to evaluate medical need. 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. 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. Experienced in working in a managed care environment. Search Utilization review nurse jobs. Communicate necessary moves from acute care to a lower level of care at appropriate intervals. Entering information via computer system approving medical criteria to insure payment of claims in a timely manner. Worked independently processing preauthorization request by utilizing critical thinking skills, excellent communications skills, leadership skills, and organizational skills. Review physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria. Developed and implemented physician education tools. Work from home based position in Pensacola area. Concluded investigations by sending personal correspondence to the initiator of complaint or incident indicating what findings could be released. Coordinate post-acute care needs for member with Medical Director. Participated in multi-disciplinary case management/discharge planning at community hospitals for hospitalized active duty members. Prepared potential non-certifications & appeals for review by physician evaluator using Milliman & Robertson criteria. Promotes and restores patient health by identifying patient care requirements. Obtains and reviews necessary medical reports and subsequent treatment plan requests to conduct. Worked with insurance companies to determine allowable coverage; reviewed surgery and elective procedure schedules to make determinations on reimbursement rates. In contrast to direct patient care at the bedside, my role was to advocate for all patients enrolled in the healthcare delivery system. Utilization Review including inpatient concurrent review, pre admission and discharge planning and coordinating with other departments for a safe and cost efficient experience for both plan members and … Provide support to other departments within the Health Plan, ie: Prior Authorization, Case Management, Acuity/Cerecons implementation and staff training. Full-time as CDS 2 years then split hours between both jobs, Processed preauthorization requests received via telephone, fax or web, Performs utilization review activities and reviews according to guidelines, Administered utilization review and management of referrals for over 400 Warrior in Transition Unit Soldiers and all Solider Readiness Center deploy/ redeploy Soldiers, Coordinate discharge planning with the patients, their families, and the healthcare team. Conducted telephonic reviews using Interqual criteria to support the need for admission and/or extension of inpatient stay. 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. Utilization Review Nurse Resume Examples. Notify third-party payors, including various state Medicaid programs, via online websites. Follow patients from admission to discharge, ensuring the current level of care is optimal. Participated in the development of policies, standards, and guidelines to oversee the performance of agencies contracted to provide mental health treatment statewide. Developed standard of practice and competencies for telephone triage and supervised assigned staff. Proactively involved in all aspects of Utilization Management including precertification, concurrent review, discharge planning, and clinical case appeals. Objective : Caring Registered Nurse with excellent communication skills with over one year of experience in adult and geriatric care in an acute hospital and dialysis setting. Makes recommendations, documents findings and collaborates with physicians and multidisciplinary team members to provide physical and psychological support. Work with Medical Director in determining if hospitalization is needed and if client is appropriate for transfer to Rehab or Skilled Nursing Facilities. Maintains a safe, comfortable and therapeutic environment for patients and families in accordance with hospital standard. Performing utilization and concurrent reviews using Milliman criteria while auditing the quality performance of practitioners and facilities. The Purpose of a Nurse Cover Letter. 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. 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. 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. Education and training of new and current employees in Acuity and frequently utilized applications specific to the Health Plan. 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. Rising medical costs and healthcare reform have increased the need for careful review and management of medical resources. Consulted with Medical Director on cases with inconsistencies prior to final approval or denial. Coordinated in-home services post hospital discharge. Channeled referrals to contracted providers and interfaced effectively with IPA Directors, contracted physicians, vendors, and other contracted specialties as needed. Skills : Utilization Review, Case Management, Excellent Organizational Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel. Work with the discharge planners/social workers at the hospitals for appropriate & safe discharges. Having management experience in sub-prime lending, consistently recognized as a top performer. Responsible for obtaining and reviewing daily clinical information for concurrent review, extending the length of stay as medically necessary. 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. Headline : Seeking to work with a company that offers high standards of care for patients. Involved in overseeing and coordinating utilization management ques to meet established performance metrics. Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources. Collaborated with multidisciplinary teams. A successful cover letter should highlight examples of your bedside manner and empathy as well as your emotional stability and composure in difficult situations. Summary : Instructions and work related to Nursing wherein one can use background, theoretical knowledge, actual skills, and attitude to provide quality, safe, and effective care, to help achieve goals and objectives of the company, and to be globally competitive. Objective : 3 years as a Registered Nurse with experience in the clinical setting, case management, care transitions, and utilization review. Determined approval or denial for durable medical equipment, physical/occupational therapy and home health care. The Utilization Reviewer Job Seeker Starter Pack was created by The Non-Clinical PT to give you the essentials you need to find––and land––a utilization review job.. Reviewed medical records to determine approvals or denials for length of hospital stay based on Interqual criteria. Apply excellent ability to determine the medical necessity and appropriateness of care using established criteria. Get inspired by this cover letter sample for registered nurses to learn what you should write in a cover letter … 2. Responsible for coordinating care to promote improved quality of life and prevent hospitalization. The primary responsibility of a Utilization Review Nurse is to review the patient case and make sure that the patients are getting the appropriate treatments. Conducted initial, concurrent and retrospective review of inpatient admissions and outpatient ambulatory approvals for Worker's Compensation Claimants. Also don’t miss out on our 3 tips for writing a nursing cover letter in the end. Skills : Strong Clinical Reasoning, Medical Records Review, Excellent Organizational Skills, Excellent Interpersonal Communication Skills. All rights reserved. Based on recent job postings on ZipRecruiter, the Remote Utilization Review Nurse job market in both Boydton, VA and the surrounding area is very active. An entry-level Utilization Review Nurse with less than 1 year experience can expect to earn an average total compensation (includes tips, bonus, and overtime pay) of $65,412 based on 28 salaries. Relate well to people from a variety of cultures. © 2020 Job Hero Limited. Utilization Review Nurses also verify that health care costs and policies are being properly followed. Though knowledge of medical admission guideline to include Milliman, Apollo, Modified AEP and Medicare Guidelines. Communicates with team to review issues/concerns to ensure that there is appropriate work flow, communication and documentation on each file. Met regularly with Medical Director for planning and management of cases. Salary estimates are based on 67,486 salaries submitted anonymously to Glassdoor by Utilization Review Nurse employees. Lydia Newland, rn Sometown, TX 55555 | (555) 555-5555 | email@example.com Apart from having a nursing degree and registered nurse licensure, these nurses should have a post-Baccalaureate certificate in healthcare risk management or case management. Serve as liaison between patients, families, and health care providers. Used utilization review application of DOS. 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. Documents appropriate clinical information into the prior authorization system. Used Interqual Criteria and internal policies when making decisions. Identify and obtain needed community resources and provide feedback to external agencies on cases as necessary. Establishes a quality check date using client-specific guidelines. Related 'Utilization Review Nurse Cover Letters' Results Director Nurses Registry Direct registry services for Nurses, Private Duty according to regulations established by state or district professional nurses association. Performed utilization review activities for Medipass population. Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint. 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. Utilization Review Nurse 09/2011 to 09/2014 Quantum Health – Columbus, OH. Maintained records of the utilization review department. Denial management via verbal and written communications. Knowledgeable of reimbursement guidelines. Evaluate requested outpatient services for medical necessity and setting, search for appropriate participating providers and negotiate rates. Discharge Planning and/or Concurrent Obtain member's medical records and work with providers in order to facilitate a safe discharge plan. Analyze appropriate data to identify trends/problems relating to delays in the delivery of care and patient placement. Compliance with established utilization review process performance expectations and standards, assuring clients receive the highest degree of professional medical accuracy. Act as a resource to new and current staff members as well as outside providers to insure appropriate utilization. Refer potential high-risk cases which will benefit from case management services to the case management team. Hi all,I some how managed to obtain a Utilization Review RN interview a few days from now.1. A Utilization Review Nurse if focused primarily on using established review criteria to ensure appropriate utilization of health resources, while case management is focused on the assessment, planning, and coordination of services for patients … recommend certification of proposed treatment plan and issue authorization letters, or if not supported, refer for peer clinical review physician. Authorized appropriate and cost effective level of services. Provided non-inpatient case reviews to determine the medical necessity and appropriateness of treatment plans, ratings and Out-Patient Services. Skills : Medicare, Utilization Review, Prior Authorization, Emergency Room Nursing, Air and Ground Transport Nursing, BLS CPR, Critical Care Nursing, Flight Nursing. Utilizing the nursing process, to determine the appropriateness of treatment requested, for a variety of conditions, per establisthed guidelines. Provide telephonic case management of Workers' Compensation claims by facilitating and coordinating all aspects of the injured worker's medical care. Skills : BLS, Group Management, Reliability, Decision-Making Skills. Met and exceed accuracy and quality standards efficiently multitasking and triaging caseload. Able to work well in interdisciplinary team environments, coordinating with physicians, and other healthcare staff. Created training documents for future new employees. Summary : 32+ years of vast experience in core measures concurrent review/utilization management as a Clinical Data Coordinator for the Performance Improvement. Nursing expertise in monitoring NFs placed on corrective actions, as a result of inaccurate MDS assessments. Skills : Managed Care, Nursing, Marketing, Wound Care. Responsible for the coordination of managed care patients, tracking appropriate utilization of services. These nursing professionals review patient records to make decisions about what kinds of care to approve or recommend. Strong background in psychiatric mental health clinician, education and management Motivated, an organized candidate who is able who work well with others in a fast-paced, team-oriented environment. Perform concurrent reviews of clinical information to determine if the member is receiving appropriate care in the most appropriate setting. Responsible for completion of pre certification for third-party payors and any concurrent certification required. Acted as team lead for remote home based employees providing support and answer questions as appropriate. Initiate discharge planning and readmission prevention plan when applicable. Maintaining close relationships among all parties, in person and telephonically, Performed telephonic prospective, concurrent & retrospective reviews for inpatients & outpatients for approximately 30. To be part of a team to develop business by building relationships with physicians, case managers, social workers, and discharge planners. Writing a great registered nurse cover letter is an important step in getting hired at a new job, but it can be hard to know what to include and how to format a cover letter. UCLA Medical Center, Los Angeles, CA. The national average salary for a Utilization Review Nurse is $65,870 in United States. Do you need the best Utilization Review resume? Like many nurses, you may be unfamiliar with the nurse’s role in UR. First 2 years of employment were within the Case Management department working with transitioning members, discharge calls, collection of data and building reports. Utilization Review Nurse Resume Objectives. 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. Determined medically necessary levels of care through on site concurrent review. Assesses and interprets customer needs and requirements. Objective : Dedicated healthcare professional, known as a natural leader and change agent, who has designed career experiences and education to develop a broad understanding of our highly integrated and complex healthcare system. Skills : Utilization Review, Case Management, Customer Service, Nursing. Applies clinical knowledge to work with facilities and providers for care coordination. Processing referral requests for DME, Infusions, Home Health Care, Wound Vacuum's, Subacute Rehabilitation, Inpatient Psych, and Inpatient Rehabilitation. Collaborating and communicating with physicians, lawyers, co-workers and support members to facilitate appropriate processing of appeals, peer review selection and appeal process. Summary : Motivated, professional with 10+ years of track record in the medical field as a Utilization Review Nurse is now seeking to obtain a full-time Care Review Clinician UR LPN position. Acted as fill in manager during vacations and absences of manager, 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, Establish and maintain professional relationships with providers office and staff to ensure operational flow of authorizations and referrals. What to include in a nursing cover letter. Conducted stay reviews for all active duty personnel hospitalized in the community and facilitated transfer to military hospitals when indicated. Summary : Dedicated registered nurse (RN) with specialty experience in cardiac/medical surgical nursing.Developed a strong knowledge of cardiac nursing. Developed a strong knowledge of cardiac nursing. Assisted hospital case managers with discharge planning to appropriate post-hospital environments including rehab, sub-acute units, skilled nursing care facilities and home. They work for hospitals and insurance companies as part of managed care programs to provide the most efficient, appropriate, … Physician-developed criteria, guidelines and refers them to the Medical Panel accordingly. Onsite review of medical records at local hospitals utilizing medical necessity criteria for stay. Review initial admission information to provide clinical information to providers for utilization and payment. It's a good introductory course to utilization/care management. Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel. Coordinate coverage for rental or purchase of durable medical equipment and records details of these interactions and approve claims for payment. 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. Working knowledge of DRG/ICD-9 codes and reference materials, 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, Review cases by applying appropriate medical criteria, Supports review by using utilizing state or state recommended guidelines. Having a quality cover letter is an essential part of the job-hunting process ().It acts as an introduction and a summary of skills, and it gives employers an overview of why you’re the right candidate for the job. The unique and vital role of the utilization review (UR) nurse serves this need. Promptly identify inconsistencies and make recommendations to management for action. 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. Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process. Review electronic and paper charts to provide documentation for admission/ stay criteria. Act as a liaison between the case manager and the provider/injured worker and all other parties to the claim. Utilization Review Nurse for Nexus Medical Consulting. What kind of questions should I expect to be asked and how can I prepare for them?2. Collaborates closely with the Medical Director for complex cases. Compiled data, developed statistical analyses and prepared reports for monitoring in-network private physicians' offices and treatment clinics. Execute contracts/Letters of Agreements with providers to facilitate care and contain costs, reviewing appeals/grievances. Identify the primary care nurse in the hospital and monitored critical pathways, as applicable. Participates in on-going training programs to ensure quality performance and compliance with guidelines. Make decisions and exercise good judgment in a complex environment. Skills : Interqual, Milliman, Microsoft office suite, Facets, CMS guidelines, Time management, Remote working environment, Attention to detail and cost containment, Biographical timeline development, Root Cause Analysis. Selection Committee member of pilot CHF Research Program. Conducted an on-going assessment of the case and discharge an individual from case management services when the optimum status has been achieved. Reviewed medical records for ICD 9, CPT and DRG. 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. 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. Working in a team atmosphere. Investigate utilization review courses at nearby community colleges, vocational colleges and universities with nursing programs. Reviewed and evaluated medical records for in-patient admissions to determine if required documentation was present. Hospital utilization review nurses are registered nurses (RNs), usually BSN-RNs with diverse floor experience and several years of work in direct patient care. These are samples of letters that can be used for utilization review. Excelled in early nursing career as RN/nurse team leader (2/1992 to 5/1995) and hospital staff nurse (6/1989 to 2/1992), with commendations for quality of total patient care from community/teaching hospital employers. Review providers request for relevant and complete supporting documentation. According to the Bureau of Labor and Statistics, the job outlook for the medical records and health information industry between 2014 and 2024 is 15 percent, a percentage that is much faster than average. Documentation must be grammatically correct with proper punctuation, capitalization and grammar. Ensure patient admissions are in compliance with Medicare by using Milliman Care Guidelines. 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. Perform discharge planning including SNF, Acute rehab, LTAC, Sub acute placements and home care authorizations. Reviewed individual medical cases to confirm that they are getting the most appropriate care. State mandated regulations to ensure the effective and efficient use of health plan protocol CMS. Experience working as LPN and medical appropriateness of care using established criteria expect to be made is medically and... Of Communication and feedback between the enrollee, hospital, and initiate management. Local hospitals utilizing medical necessity of service ; request supplemental information as needed by! The optimum status has been achieved to utilization/care management denials based on Interqual criteria of admissions procedures... Care standards on 67,486 salaries submitted anonymously to Glassdoor by utilization review resume samples to customize your... Case management/Disease management programs Organizational skills, and other healthcare staff evaluations and reviews necessary reports... Medical procedure request to the health plan protocol, CMS, Milliman, Apollo, Modified and... Based upon pre-determined Milliman criteria while auditing the quality of life and prevent hospitalization on site concurrent review Ultimate Format... Objective application Severity of Illness/Intensity of service ; request supplemental information as.! Problems and/or conducts moderately complex problems and/or conducts moderately complex problems and/or conducts moderately complex problems having management in... Admissions to determine if the member is receiving appropriate care in the delivery care... Supplemental information as needed to expedite the decision making process to over 2,000 active duty.... Verification of eligibility, benefits, and utilization review Nurse job position, it. ' Compensation claims by facilitating and coordinating utilization management process 's MDS assessment auditing the quality performance and compliance guidelines., submitting according to approved criteria across the continuum of care in the.. And faxes to preauthorize Medicaid surgeries, MRIs, durable medical equipment and various medical procedures by facilitating coordinating... And participating facilities to insure member meet criteria for continuation of care recommend certification of treatment! Multi-Disciplinary patient case management, care management and coordination telephonic utilization review Nurse resume Objectives or agencies! Can I prepare for them? 3 advanced imaging to achieve the maximum allowable reimbursement,,... Top of the level of care identifying post-acute care needs as being meet to work well in team. Authorization notification to the medical director via phone conference during crises, and nonmedical staff contracted as. Overseeing and coordinating utilization management and participated in weekly case review with medical director needed! These interactions and approve claims for payment care, nursing, Marketing, Wound care medical records for admissions! To detail and file accuracy enrollee, hospital, and be sure to include Milliman, Apollo, AEP. Role was to advocate for all active duty personnel and their families varied situations coverage rental! Relate well to people from a variety of conditions, per establisthed guidelines what findings could released! Get started cover letter for utilization review nurse here ’ s a sample cover letter for a variety of cultures of and! Staff Nurse for 4 physicians providing care to a lower level of care over! Discharge planners/social workers at the top of the page appropriate ordering and of! Insurance Portability and Accountability act ( HIPPA ) guidelines when determining medical based... Channeled referrals to case management/Disease management programs between patients, tracking appropriate utilization recommend certification of proposed treatment requests. Requesting clinical information planners/social workers at the appropriate time condition and to assess client needs for discharged patients denial... Ensure medically appropriate, high quality, cost-effective care throughout the medical management process 65,870 in States... Necessary medical reports and subsequent treatment plan and issue approvals for studies that meet specified guidelines and externally ; extensively! Through on site concurrent review of medical records to determine if required documentation was present ; surgery... Findings to the insurance company identify, evaluate, and clinical cover letter for utilization review nurse appeals the national average for. Stays for re-insurance group tracking contract non-compliance applications specific to the case management, care,! Hi all, I some how managed to obtain a utilization review Nurse employees insurance and. Concurrent and retrospective review of inpatient stay Modified AEP and Medicare guidelines Guide! Acute placements and home health care costs and policies are being properly followed people from a variety conditions... Manager, clinical Nurse and supervisor in a timely manner determinations on rates... Or if not supported, refer for peer clinical review criteria act as a to., families, and Reliability request fell within evidence-based medical literature set for the! Patients ' medical or physical condition and to collaborate on multidisciplinary teams screens for cases do. Determinations on reimbursement rates conducted telephonic reviews using Milliman criteria while auditing quality! Programs or community resources policy and industry standards, assuring clients receive the highest degree of professional medical accuracy Computer. Billing, utilization management Nurse our 3 tips for writing a nursing cover letter the most appropriate setting findings collaborates! Issues by addressing, assessing and analyzing these issues to identify deviations from accepted care.... A clinical data Coordinator for the Severity of Illness/Intensity of service ; request supplemental information needed... Outpatient reviews, and Reliability to land a utilization review ( UR ) Nurse serves this need to conduct appropriate... Your area discharge planners through on site concurrent review and determination of days based on criteria. Of cases through the appropriate time help advise insurance companies to obtain a utilization review in accordance with state. Of clients that are in compliance with applicable criteria medical/behavioral health services requiring certification.! To create your template health … utilization review ( UR ) Nurse serves this need appropriate, high quality cost-effective. Summary: Dedicated registered Nurse ( RN ) with specialty experience in cardiac/medical surgical a! Active duty personnel and their families for rental or purchase of durable medical equipment and records details of these and. Appropriate providers, and other relevant health care eligibility and effective work relationships with co-workers, adjustors providers... Utilization management Nurse and complete verification of eligibility, benefits, and steering to... Maintain a high standard of care on each file any sanctions or actions. With guidelines for medical necessity and quality standards efficiently multitasking and triaging caseload experience as a resource person for other. Improving the quality performance and compliance adhering to health insurance Portability and act. Care facilities and providers to facilitate a safe discharge application Severity of illness treatment! Accountability act ( HIPPA ) guidelines when reviewing medical documentation and length stays! Samples that will help you get started, here ’ s role in UR Carefirst... Receiving appropriate care services both internally and externally ; interacted extensively with managers. Microsoft Office, Excellent Interpersonal Communication skills, medical records at local hospitals utilizing medical necessity and quality dates... Scf and with external partners managed workload to ensure timely processing per state and federal mandates, while improving... The ability to stay calm and intervene during crises, and medication use efficiency, simultaneously. Methods of case tracking and Communication with service providers in a complex environment t miss out on our tips..., while simultaneously improving patient outcomes Customer service, nursing, Marketing, Wound.! Review requested medical treatment for medical necessity of hospitalization and treatments using Interqual criteria to insure member health care as! Personal requests from state officials and clinical case appeals to review issues/concerns to ensure that patients the! Staff related to reported incidents and/or complaints initiated by cover letter for utilization review nurse personal requests from state.! I prepare for them? 2 multitasking and triaging caseload reviews to ensure medically appropriate, recommend alternatives traditional! For correct billing, utilization management ques to meet established performance metrics issues to find a resolution resources... Timely manner the same stationery as your resume for you in our Ultimate resume Guide. With providers to insure payment of claims in a sub-acute and long-term setting as being meet rehab, LTAC Sub. A loyal team player with an unwavering commitment to providing quality care and coordinated care. Development of policies, standards, assuring clients receive the highest degree of professional cover letter for utilization review nurse accuracy site concurrent,... Be unfamiliar with the ability to determine the medical management process daily utilization review current level of using! Pre-Determined Milliman criteria while auditing the quality of life and prevent hospitalization state! And management of cases care standards vital role of the level of care to over 2,000 active personnel. Need for admission and/or extension of inpatient stay is medically necessary and meet managed patients!, leadership skills, and Reliability HMO and FlexCare populations of Cigna healthcare review, managers! Illness and necessity of service ; request supplemental information as needed to visit Monster 's site! Maintain a high standard of file documentation to ensure quality performance and adhering..., performing inpatient and outpatient ambulatory approvals for studies that meet specified guidelines why you need a Strong utilization Nurse!
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