sample resume for utilization review nurse

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Utilization Review Nurse Resume Examples

Writing a resume for a Utilization Review Nurse position requires a unique set of skills and qualifications. With the increasing demand for experienced nurses, it is important for job seekers to ensure their resumes are up-to-date and specifically tailored to the Utilization Review Nurse role. This guide will help you craft a resume that showcases your experience, skills and qualifications and will help you stand out from other applicants. We’ll provide you with example resumes, best practices and tips to help you write a resume that will help you land the Utilization Review Nurse job you’re aiming for.

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Utilization Review Nurse

123 Main Street | Anytown, USA 99999 | Phone: (123) 456-7890 | Email: [email protected]

Motivated and knowledgeable Utilization Review Nurse with 8+ years of experience in managing, evaluating, and coordinating patient care plans. Adept at developing and assessing utilization criteria to help ensure cost- effective patient care is delivered. Focused on providing quality patient care that exceeds patient and provider expectations.

Core Skills :

• Utilization management
• Clinical evaluation
• Quality of care
• Care coordination
• Regulations compliance
• Documentation and records management
• Patient assessment
• Problem solving
• Time management

Professional Experience : Utilization Review Nurse Wellhealth Medical Group, Los Angeles, CA August 2018 – Present

• Review and assess medical records and patient care plans to ensure accurate and cost- effective care delivery
• Develop and implement utilization criteria according to established guidelines
• Assess quality of care received by patients and ensure high standards are met
• Ensure appropriate second- level review is completed in order to improve quality of care
• Monitor and evaluate patient care plans and patient outcomes
• Coordinate care with other providers
• Oversee the utilization review process to ensure accuracy
• Review and update patient profiles when necessary

Utilization Review Nurse St. Mary’s Hospital, Los Angeles, CA March 2015 – August 2018

• Facilitated and implemented utilization review plans for patients
• Provided clinical evaluation and care coordination for patients
• Monitored patient outcomes post- discharge to ensure quality of care
• Ensured compliance with regulations and guidelines
• Developed and maintained accurate documentation and records
• Conducted patient assessments to ensure patient needs were met
• Provided education and counseling to patients to reinforce care plans
• Used problem- solving skills to resolve patient issues
• Managed time efficiently to complete

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Utilization Review Nurse Resume with No Experience

Recent graduate with a Bachelor of Science in Nursing, eager to use my research and organizational skills to contribute to the Utilization Review field in a meaningful way.

• Knowledgeable in medical terminology
• Excellent interpersonal and communication skills
• Strong research and organizational skills
• Proficient in Microsoft Office Suite
• Team- oriented attitude

Responsibilities

• Assessment of utilization review needs and development of appropriate plans
• Documentation of utilization review processes and outcomes
• Monitoring of utilization review activities and outcomes
• Analysis of usage patterns to help identify opportunities for appropriate utilization of healthcare services
• Collaboration with healthcare providers and staff to ensure efficient and effective utilization of healthcare services

Experience 0 Years

Level Junior

Education Bachelor’s

Utilization Review Nurse Resume with 2 Years of Experience

Dynamic and highly- skilled Utilization Review Nurse with 2 years of experience in providing health care services to a wide range of individuals. Proven track record of efficiently assessing patients’ eligibility for coverage and developing treatment strategies that are cost- effective, while meeting the highest standards of quality care. Possesses excellent communication skills, with a focus on building strong and meaningful relationships with patients, staff and providers.

Core Skills

• Utilization review
• Assessment of eligibility
• Health care services
• Patient care
• Cost- effectiveness
• Quality assurance
• Interpersonal skills
• Documentation
• Conduct utilization reviews for patients to ensure that appropriate care is provided and all coverage criteria is met.
• Identify alternative treatment methods to reduce the financial burden of care on the patient.
• Monitor patient care to ensure that the highest standards of quality are met.
• Analyze medical records for accuracy and completeness.
• Provide clinical information and support to office staff, providers, and other stakeholders.
• Assist with the development of strategies to improve the quality of care.
• Create and maintain patient profiles to ensure accurate data is on file.
• Ensure that all documentation is accurate, complete and in compliance with standards.

Experience 2+ Years

Utilization Review Nurse Resume with 5 Years of Experience

Highly capable and diligent Utilization Review Nurse with 5+ years of experience in patient assessment, discharge planning, and case management. Proven ability to develop comprehensive care plans to maximize patient health outcomes and efficiency of care delivery. Experience in collaborating with physicians, caregivers, and other healthcare professionals to ensure appropriate utilization of services and resources. Excellent communication and organizational skills leading to successful navigation throughout the healthcare system.

• Patient Assessment
• Discharge Planning
• Case Management
• Care Plan Development
• Utilization Reviews
• Collaboration
• Communication
• Organization
• Medical Record Review
• Conducted detailed assessments of patient medical needs, identifying appropriate care plans, services, and resources for discharge or continued care
• Supervised utilization reviews for inpatient and outpatient services and determined authorization for payment
• Participated in cases involving third- party payers, including Medicaid and private insurance, to ensure compliance with regulations
• Collaborated with physicians, other healthcare professionals, and patient family to develop patient care plans
• Communicated with insurance companies to obtain authorization for treatments and services
• Reviewed medical records to determine utilization of services and to monitor for quality of care
• Served as a liaison between the patient and healthcare team to ensure quality of care and best possible outcomes

Experience 5+ Years

Level Senior

Utilization Review Nurse Resume with 7 Years of Experience

Seasoned Utilization Review Nurse with 7 years of experience delivering quality patient care in acute care, long- term care and managed care settings. Highly adept in coordinating and implementing utilization review plans, training and mentoring staff, and ensuring compliance with applicable standards and regulations. Demonstrated expertise in assessing and interpreting medical information, cost- effective utilization of resources, and developing and implementing quality improvement initiatives.

• Utilization Review
• Quality Assurance
• Collaborative Care
• Regulatory Compliance
• Data Analysis
• Team Leadership
• Interdisciplinary Management

Responsibilities :

• Coordinate and implement utilization review plans in line with organizational standards and regulations.
• Review and analyze clinical data for medical necessity and cost- effectiveness of treatments and medications.
• Provide timely and accurate information to healthcare professionals regarding utilization standards, quality and data management.
• Monitor staff performance and provide guidance and training to ensure compliance with utilization review plans.
• Utilize quality assurance and data collection methods to evaluate and document utilization and cost trends.
• Facilitate interdisciplinary meetings and coordinate education programs to promote cost- effective utilization of care.
• Educate and mentor staff on utilization review processes and data analysis.

Experience 7+ Years

Utilization Review Nurse Resume with 10 Years of Experience

Committed Utilization Review Nurse with 10+ Years of experience providing comprehensive health care services for patients in an inpatient and outpatient setting. Adept at coordinating, directing and monitoring the utilization of health care resources. Skilled at analyzing care documentation, determining appropriateness of services, and providing the necessary resources. Strong background in working with health insurance and managed care organizations, performing quality assurance reviews and auditing to increase patient satisfaction.

• Utilization Management
• Health Insurance
• Patient Documentation
• Medical Necessity
• Utilization Audit
• Resource Utilization
• Reviewed and assessed medical necessity of services and submitted concurrent reviews to insurance companies
• Performed utilization and case management functions in accordance with state and federal regulations
• Evaluated patient medical records for accuracy and completeness and recommended modifications for optimal care
• Established and maintained communication with health care providers, managed care organization and payers
• Provided consultation on utilization management issues to interdisciplinary team
• Monitored and tracked utilization data and trends, and implemented strategies to reduce utilization and cost
• Generated reports of clinical reviews and utilization activities to management team.

Experience 10+ Years

Level Senior Manager

Education Master’s

Utilization Review Nurse Resume with 15 Years of Experience

Utilization Review Nurse with 15 years of experience in reviewing medical records, assessing medical necessity and determining coverage. Possesses an in- depth knowledge of medical coding, insurance policies and procedures, and regulatory requirements. Passionate about providing patients with the best quality care in the most cost- effective manner.

• Knowledgeable in utilization review standards, regulations, and procedures
• Proficient in medical coding and insurance policies
• Skilled in providing patient care with cost- effectiveness
• Excellent in problem- solving and decision- making
• Ability to multi- task and prioritize workload
• Reviewed and assessed medical records to determine coverage and medical necessity
• Applied medical coding and understanding of insurance policies to determine coverage eligibility
• Evaluated treatment options for cost- effectiveness and appropriateness
• Developed plans of care and appropriate authorization requirements
• Established appropriate discharge planning and post- discharge care
• Monitored and audited utilization of services to ensure compliance
• Participated in Utilization Review committees to assess utilization trends
• Provided education to staff regarding utilization review policies and procedures

Experience 15+ Years

Level Director

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What should be included in a Utilization Review Nurse resume?

Writing a resume as a utilization review nurse can be daunting, as there are so many skills and qualifications you must highlight. However, it doesn’t have to be a challenge. Here are some tips and items to include to ensure your resume is comprehensive and effective:

• Education: A utilization review nurse should include information about their educational background, including the name of the school they attended, the degree they earned and any relevant certifications they possess.
• Experience: List all the previous positions you have held as a utilization review nurse, including the name of the organization, the duration of employment, and your job title.
• Skills: Highlight the skills and qualifications that make you a great utilization review nurse, such as knowledge of health insurance laws, strong organizational abilities, and excellent communication and interpersonal skills.
• Professional Affiliations: Make sure to include any professional memberships or affiliations you have, such as membership in the American Association of Utilization Review Nurses (AURN).
• Awards and Honors: If you have been recognized and honored for your work as a utilization review nurse, make sure to include that information.

These are just some of the items that should be included in a utilization review nurse resume. By following these tips, you can ensure that your qualifications and experience are highlighted in the most effective way.

What is a good summary for a Utilization Review Nurse resume?

A Utilization Review Nurse resume should focus on their experience and accomplishments in utilization review, medical case management, and discharge planning. It should emphasize their ability to facilitate communication between patients, their families, and healthcare providers. They should highlight their ability to evaluate patient care requests thoroughly and accurately, their understanding of state and federal regulations, and their aptitude for communicating with insurance companies. The resume should also detail their familiarity with medical terminology and coding, as well as their outstanding organizational and multitasking skills.

What is a good objective for a Utilization Review Nurse resume?

A Utilization Review Nurse (URN) is a registered nurse who is responsible for ensuring the quality and cost-effectiveness of patient care. The URN performs assessments of patient care and utilization of health care services to ensure they are appropriate, necessary and cost-effective. A good objective for a URN resume should reflect an understanding of the role and its importance in the health care system.

• Demonstrate extensive experience in the field of utilization review, including expertise in assessing patient care and utilization of health care services.
• Possess strong knowledge of the principles and regulations of utilization review.
• Utilize analytical and problem-solving skills to ensure the quality, cost-effectiveness and appropriateness of patient care.
• Ability to collaborate and communicate effectively with other health care professionals, patients, and other stakeholders.
• Commitment to providing excellent patient care and delivering quality outcomes.
• Dedication to upholding ethical principles and professional standards in the health care system.

How do you list Utilization Review Nurse skills on a resume?

When you are creating a resume for a Utilization Review Nurse position, it is important to ensure that you include the skills and qualifications that will show employers you have the expertise they need. Utilization Review Nurses are responsible for ensuring that patients receive the care they need without over-utilizing services or running up excessive costs. To showcase your qualifications for a Utilization Review Nurse role, include the following skills on your resume:

• Knowledge of health care plans, benefits and utilization review: Utilization Review Nurses must have an understanding of the various health care plans available and how they impact patient care and cost.
• Ability to analyze and interpret medical records: Utilization Review Nurses must be able to review medical records, assess patient care plans, and provide recommendations to ensure the most cost-effectively care options are selected.
• Experience with medical coding and billing: Utilization Review Nurses must be familiar with medical coding and billing practices to ensure that patients are billed correctly and given the right care at the right time.
• Ability to communicate in a professional manner: Utilization Review Nurses need to be able to communicate with a variety of professionals, including doctors, nurses, and office staff, in a professional manner.
• Attention to detail: Utilization Review Nurses must be able to review and follow up on patient records in an accurate and timely manner.
• Problem solving skills: Utilization Review Nurses must be able to identify and address any issues that arise in the care of patients.

By highlighting these skills on your resume, you can showcase your qualifications for a Utilization Review Nurse role and demonstrate to potential employers that you are the right person for the job.

What skills should I put on my resume for Utilization Review Nurse ?

As exciting as the field of Utilization Review Nursing may be, you know that you need to put together an impressive resume in order to stand out from the competition and get the job you really want. When it comes to preparing your resume, it is important to focus on the skills that will be the most beneficial for this position. Here are some of the skills you should consider adding to your resume for a Utilization Review Nurse position:

• Knowledge of Medical Terminology: A Utilization Review Nurse must be familiar with a wide range of medical terms and be able to accurately interpret and apply them.
• Interpersonal Skills: This position requires strong interpersonal skills in order to effectively communicate with patients and other healthcare staff.
• Computer Skills: Being able to utilize computer programs and other technology for data entry, gathering information, and analyzing data is a must for this role.
• Organization Skills: Utilization Review Nurses must be organized in order to keep track of patient information and medical records and ensure that all data is properly documented.
• Attention to Detail: Being able to review and analyze patient data and medical records while maintaining accuracy is essential.
• Critical Thinking: Utilization Review Nurses must be able to think critically and make decisions quickly and efficiently.
• Problem Solving: The ability to assess and solve problems related to patient care is essential.

By highlighting the skills listed above on your resume, you will be able to demonstrate your qualifications for a Utilization Review Nurse position and stand out from the competition. Good luck!

Key takeaways for an Utilization Review Nurse resume

When it comes to crafting a strong resume for an Utilization Review Nurse, there are several key takeaways to keep in mind. A clear understanding of the responsibilities of a Utilization Review Nurse, as well as their role in the healthcare system, is essential if you want to create an effective resume that will get you noticed. Here are some key takeaways to consider when preparing a resume for an Utilization Review Nurse.

• Demonstrate your knowledge: Utilization Review Nurses have an important role in the healthcare system, so it is important that your resume displays your knowledge of the profession. Include information about your specific experience in a utilization review setting, as well as your familiarity with the relevant regulations and standards.
• Highlight your experience: A successful Utilization Review Nurse should possess a number of skills, so be sure to highlight your experience with them. For example, list any previous experience with coding, data analysis, and Medicare and Medicaid guidelines.
• Showcase your communication skills: A Utilization Review Nurse must be able to effectively communicate with other healthcare professionals, so make sure your resume features your communication skills. Include any prior experience with customer service, as well as any examples of successful collaborations you have participated in.
• Show your problem-solving abilities: Utilization Review Nurses are often called upon to solve complex problems, so use your resume to showcase your problem-solving abilities. Include examples of times you have identified cost-savings opportunities or streamlined processes.
• Describe your certifications: Utilization Review Nurses must be certified in order to practice, so make sure your resume lists any certifications you have obtained. Additionally, list any professional organizations or associations you belong to, as this displays your commitment to the profession.

By using these key takeaways when crafting your resume, you can create a comprehensive and effective document that will demonstrate

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Utilization Review Nurse Resume Example for 2024: Free Downloadable Templates

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Table of Contents

As the healthcare industry continues to evolve, the role of a Utilization Review Nurse has become increasingly critical in ensuring that patients receive appropriate care while managing costs effectively. This position involves assessing the necessity and efficiency of healthcare services, making it essential for professionals in this field to showcase their expertise and experience through a compelling resume. A well-crafted resume not only highlights your qualifications but also sets you apart in a competitive job market. In this guide, we will walk you through the nuances of writing a standout Utilization Review Nurse resume, providing you with the tools necessary to capture the attention of hiring managers and secure your next position.

Throughout this article, we will cover key points essential for crafting an impactful resume tailored for Utilization Review Nurses. You will learn about the specific responsibilities and skills that should be highlighted, and the best formats to use for maximum effect. We will also discuss common mistakes to avoid that can hinder your chances of landing an interview. Additionally, you’ll find resume examples catering to various levels of experience, along with valuable tips on effective resume writing techniques. Finally, we will guide you in selecting the right resume templates to ensure that your application stands out in the best possible way. Whether you're a seasoned professional or just starting in this field, this comprehensive guide is designed to help you succeed in your job search.

Key Responsibilities and Skills for a Utilization Review Nurse

Utilization Review Nurses play a critical role in the healthcare system by assessing patient care and ensuring that services provided are necessary and appropriate. Their key responsibilities include:

• Conducting evaluations of patient records and treatment plans to determine medical necessity and appropriateness of care.
• Collaborating with healthcare providers, insurance companies, and patients to facilitate effective communication regarding treatment options and coverage.
• Monitoring and analyzing utilization patterns to identify areas for improvement in patient care and resource management.
• Ensuring compliance with healthcare regulations, policies, and standards during the review process.
• Preparing detailed reports and documentation related to utilization review findings and recommendations.

To excel in this role, a Utilization Review Nurse must possess a set of essential skills, including:

• Strong analytical skills to assess patient data and treatment plans effectively.
• Excellent communication skills for liaising with healthcare teams, patients, and insurers.
• Knowledge of healthcare regulations, coding, and billing practices.
• Critical thinking abilities to make informed decisions regarding the necessity of care.
• Proficiency in electronic health records (EHR) systems and utilization review software.

Highlighting these skills effectively in the resume skills section is crucial for showcasing your qualifications to potential employers. Tailoring these responsibilities and skills to match the specific job description will demonstrate your understanding of the role and your suitability for the position. Additionally, consider how these skills can be relevant in crafting a strong CV that reflects your expertise and achievements in utilization review nursing.

Best Resume Format and Structure for a Utilization Review Nurse

When crafting a resume for a Utilization Review Nurse position, it’s essential to choose a format that effectively highlights your qualifications and experience. Here’s a detailed guide on the best resume format and structure to help you stand out:

Contact Information Place your contact information at the top of your resume. This should include:

• Phone Number
• Professional Email Address
• LinkedIn Profile (optional)
• Location (City, State)

Professional Summary Following your contact information, include a concise professional summary. This section should be 2-3 sentences long and summarize your experience, skills, and what you bring to the Utilization Review role. Focus on your nursing background, familiarity with utilization review processes, and any notable achievements.

Work Experience This is one of the critical sections of your resume. List your work experience in reverse chronological order. For each position, include:

• Company Name
• Dates of Employment (Month/Year to Month/Year)
• Bullet points that outline your responsibilities and achievements. Use action verbs and quantify your accomplishments whenever possible. Highlight experiences related to patient care, collaboration with multidisciplinary teams, and any specific utilization review tasks you performed.

Education In this section, provide details of your educational background. Include:

• Degree(s) Earned (e.g., Bachelor of Science in Nursing)
• University/College Name
• Graduation Date (Month/Year)
• Additional relevant coursework or honors can be included if applicable.

Skills Create a section to list your relevant skills. Tailor this to include both hard and soft skills that are pertinent to a Utilization Review Nurse, such as:

• Knowledge of healthcare regulations and compliance
• Proficient in electronic health record (EHR) systems
• Strong analytical and critical thinking abilities
• Effective communication and interpersonal skills
• Ability to work collaboratively with healthcare teams

Certifications List any relevant certifications that enhance your qualifications. This may include:

• Registered Nurse (RN) License
• Certified Case Manager (CCM)
• Utilization Review Certification (URAC)
• Other relevant certifications (if applicable)

Additional Tips

• Choose the Right Format: A chronological resume format is often best for showcasing your work history and progression in the nursing field. However, if you are changing careers or have gaps in your employment, consider a functional or combination format.
• Tailor Your Content: Customize your resume for each job application by using keywords from the job description. This not only helps in passing applicant tracking systems but also shows your alignment with the specific role.
• Keep It Concise: Aim for a one-page resume, especially if you have less than 10 years of experience. If you have extensive experience, you can extend to two pages but ensure every entry is relevant.

The format you choose for your resume can complement your cover letter format as well. A clean, professional design for both documents creates a cohesive application package. Ensure that both your resume and cover letter share similar fonts, colors, and styling to present a unified professional image. Use your cover letter to elaborate on your experiences mentioned in the resume, providing context and demonstrating your enthusiasm for the Utilization Review Nurse position.

By following this structured approach, you will create an impactful resume that effectively communicates your qualifications and readiness for a Utilization Review Nurse role.

Writing Tips and Best Practices for a Utilization Review Nurse Resume

When crafting a resume as a Utilization Review Nurse, it's essential to showcase your clinical expertise, analytical skills, and knowledge of healthcare regulations in a clear and professional format. Start by tailoring your resume to the specific job you're applying for, emphasizing relevant experience and skills that align with the job description. Incorporate strong action verbs to convey your responsibilities and achievements effectively. Additionally, quantifying your accomplishments can provide potential employers with a clearer picture of your capabilities and contributions. Remember to use industry-specific keywords that reflect the terminology and nuances of the Utilization Review field. For a polished presentation, refer to resume writing tips that can elevate your document's professionalism. Finally, consider how these best practices can also enhance your cover letter by making it more compelling and aligned with the job requirements.

• Use action verbs like "analyzed," "managed," "coordinated," and "evaluated" to start bullet points and demonstrate your active role in previous positions.
• Quantify your achievements, such as the percentage of claims approved or the number of patient evaluations conducted, to provide measurable impact.
• Incorporate relevant industry-specific keywords such as "utilization review," "clinical guidelines," "case management," and "healthcare compliance" to pass through applicant tracking systems.
• Highlight your familiarity with medical coding and billing processes, as this is often crucial in utilization review roles.
• Tailor your skills section to reflect both hard skills (like data analysis) and soft skills (like communication and collaboration) that are essential for the role.
• Keep your resume concise, ideally one page, focusing on the most relevant experiences from your nursing career.
• Ensure the format is clean and easy to read, with consistent fonts and spacing to create a professional appearance.
• Proofread your resume multiple times to eliminate any grammatical errors or typos, as attention to detail is vital in the healthcare field.

Common Mistakes to Avoid in a Utilization Review Nurse Resume

Crafting a compelling resume as a Utilization Review Nurse is crucial for standing out in a competitive job market. However, many candidates make common mistakes that can undermine their chances of landing an interview. Awareness of these pitfalls can significantly enhance the effectiveness of your resume. Here are some key mistakes to avoid:

• Overloading your resume with excessive information, making it cluttered and hard to read.
• Using generic descriptions that fail to highlight specific skills and achievements relevant to utilization review.
• Neglecting to tailor your resume for the specific job you are applying for, which can make it appear less relevant.
• Failing to quantify accomplishments, such as the number of reviews completed or improvements in patient care metrics.
• Ignoring the importance of clear formatting, which can lead to a lack of professionalism.
• Including outdated certifications or failing to mention current relevant credentials.
• Misstating your job titles or responsibilities, which can be easily verified by potential employers.
• Using passive language instead of strong action verbs, which can make your contributions seem less impactful.
• Overlooking the importance of proofreading for typos and grammatical errors that can detract from your professionalism.
• Not including keywords from the job description that can help your resume get past applicant tracking systems.

To further enhance your job application, consider reviewing the common mistakes to avoid in a resume . Additionally, pay attention to common cover letter mistakes that should also be avoided to ensure a cohesive and compelling application package.

Sample Utilization Review Nurse Resumes

A well-crafted resume is essential for showcasing your qualifications as a Utilization Review Nurse. Whether you're an experienced professional, an entry-level candidate, or transitioning from a different career, having a tailored resume can significantly impact your job search. Below are three sample resumes to guide you in creating your own.

Experienced Utilization Review Nurse

Jane Doe, RN, BSN 123 Health St. City, State, Zip (123) 456-7890 [email protected]

Professional Summary Dedicated and detail-oriented Utilization Review Nurse with over 8 years of experience in healthcare. Proven track record of conducting thorough patient assessments, reviewing medical records, and ensuring compliance with healthcare policies. Expertise in collaborating with healthcare teams to optimize patient care while managing costs.

Core Competencies

• Utilization Review
• Patient Advocacy
• Healthcare Policy Compliance
• Medical Record Review
• Interdisciplinary Collaboration
• Quality Assurance

Professional Experience Utilization Review Nurse ABC Health Services, City, State March 2018 – Present

• Conduct comprehensive reviews of patient care plans to ensure compliance with insurance policies and regulations.
• Collaborate with physicians and healthcare providers to develop cost-effective treatment plans.
• Implement quality assurance measures that improved patient outcomes by 15% over two years.
• Train and mentor junior nurses on best practices in utilization review and documentation.

Staff Nurse XYZ Hospital, City, State June 2015 – March 2018

• Provided direct patient care in a fast-paced environment, managing a caseload of 10 patients daily.
• Assisted in developing patient discharge plans and coordinated with community resources for post-hospital care.
• Participated in patient education initiatives, enhancing patient understanding of treatment options.

Education Bachelor of Science in Nursing (BSN) University of State, City, State Graduated: May 2015

Certifications

• Registered Nurse (RN)

Entry-Level Utilization Review Nurse

John Smith, RN 456 Care Ave. City, State, Zip (987) 654-3210 [email protected]

Professional Summary Motivated and compassionate recent nursing graduate with a solid foundation in patient care and a keen interest in utilization review. Eager to leverage clinical skills and knowledge of healthcare regulations to ensure optimal patient outcomes and resource utilization.

• Patient Assessment
• Medical Terminology
• Clinical Documentation
• Critical Thinking
• Team Collaboration
• Time Management

Professional Experience Nursing Intern LMN Medical Center, City, State January 2023 – May 2023

• Assisted nursing staff in assessing patients and developing care plans under supervision.
• Participated in interdisciplinary team meetings to discuss patient care strategies.
• Conducted patient education sessions on medication adherence and discharge instructions.

Volunteer Nurse Health Outreach Program, City, State June 2022 – August 2022

• Provided nursing care and support for underserved populations during community health initiatives.
• Collected health data and assisted in the documentation of patient information.

Education Bachelor of Science in Nursing (BSN) University of State, City, State Graduated: May 2023

Career Changer to Utilization Review Nurse

Emily Johnson 789 Wellness Blvd. City, State, Zip (321) 654-9870 [email protected]

Professional Summary Results-driven healthcare professional transitioning to a Utilization Review Nurse role with a background in healthcare administration and a passion for patient advocacy. Strong analytical skills and experience in managing healthcare processes, seeking to ensure efficient resource utilization and high-quality patient care.

• Healthcare Administration
• Data Analysis
• Cost Management
• Policy Development
• Communication Skills
• Project Management

Professional Experience Healthcare Administrator PQR Hospital, City, State June 2019 – Present

• Managed operational processes, improving efficiency by 20% through streamlined workflows.
• Developed and implemented policies to enhance patient care and compliance with regulatory standards.
• Collaborated with clinical teams to analyze patient data and identify areas for improvement.

Administrative Assistant GHI Medical Group, City, State August 2016 – May 2019

• Supported the healthcare team with patient scheduling, insurance verification, and data entry.
• Assisted in the coordination of patient care services and ensured adherence to organizational policies.

Education Master of Health Administration (MHA) University of State, City, State Graduated: May 2019

• Certified Healthcare Administrative Professional (cHAP)

For further inspiration, explore more resume templates . Additionally, corresponding cover letter examples can help you create a complete job application package.

Checklist for a Utilization Review Nurse Resume

• Proofread for Typos and Errors: Carefully review your resume for any spelling, grammar, or punctuation mistakes. Consider reading it aloud or asking a friend to review it for a fresh perspective.
• Check for Consistency: Ensure that your formatting is uniform throughout the document. This includes font size, bullet points, and spacing. Consistency enhances readability.
• Tailor to the Job Description: Customize your resume for each application by incorporating relevant keywords and phrases from the job description. This shows that you are a good fit for the specific role.
• Highlight Relevant Experience: Focus on your experience related to utilization review, including specific achievements, metrics, and responsibilities that align with the job requirements.
• Include Relevant Certifications: Make sure to list any nursing licenses, certifications, or training that are pertinent to utilization review, such as Certified Utilization Review Nurse (CURN).
• Quantify Achievements: Whenever possible, use numbers to quantify your achievements (e.g., "Reviewed and approved 200+ patient cases monthly, achieving a 95% accuracy rate").
• Professional Summary: Write a compelling professional summary that encapsulates your skills, experience, and what you bring to the role. This should be tailored to highlight your strengths in utilization review.
• Contact Information: Ensure your contact information is correct and up to date, including your phone number, email address, and LinkedIn profile if applicable.
• Use an AI Resume Builder: Consider using an AI resume builder to ensure that all elements are well-organized and visually appealing, making it easier for recruiters to read.
• Adapt for CV or Cover Letter: Remember that a similar checklist can be followed for creating a CV or cover letter , ensuring consistency and professionalism across all your application materials.

Key Takeaways for a Utilization Review Nurse Resume Guide

As you embark on the journey to create an impactful Utilization Review Nurse resume, remember that the examples and tips provided are your stepping stones to success. By tailoring your resume to highlight your clinical expertise, analytical skills, and understanding of healthcare policies, you’ll be well-equipped to stand out in a competitive job market. To further enhance your application, consider downloading a tailored resume template from resume templates or a professional cover letter template from cover letter templates . For a more personalized approach, explore our best resume maker to craft a resume that reflects your unique qualifications. Additionally, following similar guidelines will assist you in creating a compelling CV and an engaging cover letter . Take these next steps to ensure your application stands out and showcases your strengths as a Utilization Review Nurse.

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Utilization Review Nurse Resume Sample

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Work Experience

• Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications
• Current active unrestricted license or certification to practice as a health professional within the scope of licensure in the State of TN required
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistentwith the member's eligibility, benefits and contract
• Applies clinical knowledge to work with facilities and providers for care-coordination
• Current active unrestricted license or certification to practice as a health professional within the scope of licensure in the State of VA or TN required
• Plans, directs, assigns, and evaluates the work of subordinates engaged in utilization review activities
• Plans, develops, and implements procedures to fulfill the requirements and guidelines for an effective and timely utilization review system
• Confers with physicians, administrative personnel, and other disciplines in the hospital to coordinate the work of the unit, obtain information, answer questions concerning the necessity for utilization review, and develop review procedures
• Determines need for and conducts in-service training to improve quality of admission and continued stay reviews, and to disseminate information concerning new or revised procedures
• Works with Professional Standards Review Organization representative to orient new staff to Federal laws and regulations pertaining to Medicare and Medi-Cal reimbursement
• Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for the referral of unusual questionable cases, on referred cases for reconsideration, and to obtain authorization for the issuance of denial letters
• Reviews, retrospectively, utilization review records for completeness, use of appropriate codes, correctness of primary reason for admission and certified hospital days, and inclusion of all relevant supporting medical information
• Develops procedures for the compilation of information from medical charts concerning particular diagnoses, problems, procedures, or practitioner categories as directed for medical care evaluation studies
• Prepares and analyzes reports on number and status of reviews, physician advisor referrals, and type of physician advisor determinations to determine if improvement in procedures or additional staff training is needed, and to make recommendations on potential areas for medical care evaluation studies
• Attends Utilization Review Committee meetings to inform the committee of new or revised utilization review requirements, the impact of the requirements, and procedures to be implemented for compliance, as needed
• As a unit supervisor at the LAC-USC Medical Center
• Has immediate responsibility for organizing, assigning, and evaluating the work of at least seven Utilization Review Nurses
• Acts as a technical resource person to subordinate staff concerning Federal regulations pertaining to Medicare and Medi-Cal reimbursement, aspects of medical treatment for unusual illnesses and diseases, and interpretation of review procedures and standards
• Participates in the formulation of and changes in utilization review procedures by assessing the effectiveness of the review system and providing information on the policies and procedures within the assigned medical areas
• Provides input for the in-service training program by identifying areas of deficiency in staff knowledge or experience
• Analyzes cases for referral to the physician advisor to ensure that the admission or continued stay is being questioned based upon appropriate screening criteria and standards; serves as the liaison with the physician advisor for follow up on referrals
• Compiles data on number and status of reviews, physician advisor referrals, and type of physician advisor determinations
• Maintains effective working relationships with unit physicians to facilitate the execution of the utilization review system
• Participates in the work performed by subordinates
• Work retro Medicaid and prebill accounts efficiently and effectively obtaining authorizations for entire length of stay
• Evaluates clinical documentation on multiple patient accounts and escalates issues through the established chain of command

Professional Skills

• Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines
• Strong organizational skills and able to proactively prioritize needs and effectively manage resources
• Experience with clinical applications/systems. Excellent analytic, research, and problem solving skills
• Excellent organizational, written, and interpersonal skills and the ability to anticipate and solve problems and communicate clearly and effectively
• Excellent communication, organization, and interpersonal skills. Car and valid driver’s license required
• PC Skills– demonstrates advanced proficiency in Microsoft Office applications and others data mining software
• Possesses strong mentoring skills

How to write Utilization Review Nurse Resume

Utilization Review Nurse role is responsible for interpersonal, computer, clinical, organization, basic, medical, facilitation, microsoft, analytical, leadership. To write great resume for utilization review nurse job, your resume must include:

• Your contact information
• Work experience
• Skill listing

Contact Information For Utilization Review Nurse Resume

The section contact information is important in your utilization review nurse resume. The recruiter has to be able to contact you ASAP if they like to offer you the job. This is why you need to provide your:

• First and last name
• Telephone number

Work Experience in Your Utilization Review Nurse Resume

The section work experience is an essential part of your utilization review nurse resume. It’s the one thing the recruiter really cares about and pays the most attention to. This section, however, is not just a list of your previous utilization review nurse responsibilities. It's meant to present you as a wholesome candidate by showcasing your relevant accomplishments and should be tailored specifically to the particular utilization review nurse position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions.

Representative Utilization Review Nurse resume experience can include:

• Strong computer skills including the ability to rapidly learn and use new applications
• Strong experience in chart review and discharge planning, ER and ICU experience
• Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Strong experience in chart review, discharge planning, Med Surg and ICU
• Strong experience in chart review, discharge planning, Med Surge and ICU
• Computer skills and typing expertise

Education on an Utilization Review Nurse Resume

Make sure to make education a priority on your utilization review nurse resume. If you’ve been working for a few years and have a few solid positions to show, put your education after your utilization review nurse experience. For example, if you have a Ph.D in Neuroscience and a Master's in the same sphere, just list your Ph.D. Besides the doctorate, Master’s degrees go next, followed by Bachelor’s and finally, Associate’s degree.

Additional details to include:

• School you graduated from
• Major/ minor
• Year of graduation
• Location of school

These are the four additional pieces of information you should mention when listing your education on your resume.

Professional Skills in Utilization Review Nurse Resume

When listing skills on your utilization review nurse resume, remember always to be honest about your level of ability. Include the Skills section after experience.

Present the most important skills in your resume, there's a list of typical utilization review nurse skills:

• Excellent time management and problem solving-skills
• Demonstrated knowledge of pathophysiology with application of critical thinking skills
• Three years prior nursing experience in a hospital required with previous utilization review experience required
• Excellent analytic, research, and problem solving skills
• Strong organization skills, self-directed, flexible, able to adapt to rapidly changing regulatory requirements
• Solid analytical, assessment and documentation skills

List of Typical Experience For an Utilization Review Nurse Resume

Experience for utilization review nurse auditor resume.

• Proficient in MS word and excel applications. Previous experience working in an electronic medical record system
• Demonstrates excellence in communications to ensure customer satisfaction and retention
• Utilizes nationally recognized evidenced based guidelines to make medical necessity decisions
• Completing concurrent reviews for caseload to extend clients’ length of stay
• Participates in coordinating on-going education for Case Management staff regarding government and payor regulatory and outcomes
• Work assigned accounts in eRequest to resolve outstanding issues
• Report insurance denial trends identified during daily operational assignments
• Adhere to all policies and procedures, including, attendance, phone and internet usage, break utilization, etc

Experience For RN Utilization Review Nurse Bedford, Texas Resume

• Participate in education and training as needed
• Serves as the primary contact for all payors regarding utilization review and management issues
• Assess the needs for a Medicare IM, delivers admission notice if not already done so by admitting
• Collaborates with the third party payers to anticipate denial of payment and proactively addresses issues contributing to a potential denial
• Contacts the attending physician to notify him/her of all decisions to issue a notice of non-coverage for all payers
• Maintains productivity and meets all UR performance standards according to department policies and procedures
• Attends education sessions each year for internal and external customers regarding utilization management
• Graduate of an accredited practical/vocational or professional nursing program

Experience For Utilization Review Nurse Supervisor Resume

• Handles complex, high acuity cases, and/or account sensitive cases involving largest reserves
• Current/active Nursing License - needs to be licensed in Georgia and Alabama- strictly telephonic
• Provide assistance to physicians and hospital staff with discharge planning to expedite hospital discharge
• Support orientation program for UR staff by acting as primary mentor for review nurse and physician reviewers
• Conducts service connection reviews using Quadramed and also assists with clinical reviews as directed by the CBO: i.e., The Combat Vet Project
• Responsible/accountable for professional development and maintaining licensure
• Function as subject matter expert for Wyoming Disability Determination reviews as well as complete additional utilization management specialty reviews
• Perform accurate and timely documentation of all review activities based on policy and procedure

Experience For Telephonic Utilization Review Nurse Onsite Resume

• Contact facilities, physicians’ offices and/or insurance companies to resolve denials/appeals if needed
• Demonstrates knowledge of regulatory requirements, Ethics and Compliance policies, and quality initiatives; monitors self-compliance and implements process changes to ensure compliance to such regulations and quality initiatives
• Establish and maintain relationships with all customers
• Seeks assistance from immediate supervisor when in situations which are unclear or ambiguous
• Performs concurrent payor reviews for medical appropriateness for patients placed in outpatient observation or in an inpatient setting according to payor guidelines, rules and regulations
• Contacts the scheduling provider to get the correct status order for the scheduled procedure and/or secure documentation to support an ordered status or level of care
• Ensures inpatient vs. outpatient scheduling criteria is met in accordance with the payor and CMS requirements (inpatient only procedures)
• Establishes and maintains professional, collaborative working relationships with the Business Office Registration Department, Revenue Cycle Department and other key departments to facilitate processes to ensure timely and appropriate reimbursement for services provided

Experience For Utilization Review Nurse LPN Resume

• Initiates and coordinates the payor appeal process for all concurrent denials including arranging a scheduled time for the attending physician and payor Medical Director to discuss the clinical situation
• Completes an initial screen of all patients within 24 hours of admission utilizing specific criteria to identify needs related to utilization management
• Conducts retrospective medical appropriateness review as identified by internal and external audit and/or payor denials
• Meets Initial Clinical Review URAC Standards below
• Evaluates patients for appropriateness of admission type and setting, utilizing a combination of clinical information, screening criteria and third party information
• Appropriately uses Interqual criteria for leveling of care
• Completes CERME assessment, daily
• Ensures appropriate physician admission orders and level of care documentation by the physician
• Monitors physician compliance with the CMS 2 midnight rule

Experience For Utilization Review Nurse RN Resume

• Conducts concurrent admission and continued stay reviews based on appropriate utilization criteria, established standards, procedures and policies
• Documents authorization numbers, days approved data, and denial data as outlined in the departmental policy and procedures
• On a daily basis, identifies cases that fail to meet criteria and promptly reviews the case with the patient’s physician to resolve the issue
• Proactively follows and intervenes on open cases to include concurrent appeals of denials
• Educates staff and physicians about managed care principles, observation status, reimbursement rules and range of patient care setting beyond observation, intensive care and acute hospitals
• Delivers second IM notice to Medicare recipients if appropriate, facilitating appeal if needed

Experience For Network Utilization Review Nurse Resume

• Works collaboratively with all Revenue Cycle departments to ensure accurate, timely communication regarding changes in patient status information
• Attends required education to maintain competency with CERME and other UR systems
• Collaborates with members of the multidisciplinary team to facilitate the case management and care coordination processes for the assigned caseload
• Consults with medical staff as needed to facilitate accurate documentation and to assure an appropriate timely discharge. Monitors and ensures physician compliance with the CMS 2 midnight rule
• Monitors patient progress and plan of care with the aid of internal and external utilization guidelines
• Contributes in a positive manner to the development of the UR department
• Communicates information in a clear and timely manner
• Participates in quality improvement and evaluation processes related to the CM practice
• Participates in the development of procedures, roles, systems and structures related to the UR practice

Experience For Pre-certification / Utilization Review Nurse Resume

• Interacts with patients, families, colleagues and external contacts with respect, sensitivity and attentiveness to promote teamwork and cooperation
• Adheres to UR department specific and organizational policies and standards such as TJC, Dept of Health, etc
• UR’s are on site and available seven days a week
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews within scope of licensure by utilizing appropriate medical policies and clinical guidelines in compliance with department guidelines and consistent with the members eligibility, benefits and contract
• Educates the member about plan benefits and contracted physicians, facilities and healthcare providers. Refers treatment plans/plan of care to peer clinical reviewers in accordance with established criteria/guidelines and does not issue medical necessity non-certifications
• A current, valid Michigan license to practice as a Registered Nurse without any conditions, limitations or restrictions

Experience For Associate Utilization Review Nurse, LPN Resume

• Applies worker’s compensation regulations, state laws and guidelines to case management activity in assigned territories
• Coordinates level of service justification directly with physician and communicates directly with third party payer to obtain approval
• Interact with social worker, community agencies to identify alternate delivery of services
• Reviews and/or coordinates requests for authorization of specialty services with external consultants, and Physician Advisors; Uses his/her own discretion in determining if submitted medical information needs a consultant’s review
• Educates external providers about HPHC’s utilization management guidelines for specialty services

Experience For Licensed Utilization Review Nurse Resume

• Licensed Practical Nurse (LPN) with current state license
• Communicating with the insurance department if a client does not have coverage or there are limitations on client’s policy that becomes available as case is opened with insurance company
• Working with clinical and client care team to communicate insurance case manager’s request for specific treatment, follow ups, and individualized care
• Participates in Contracting and Provider Relations activities as necessaryto develop and maintain provider networks. Identify and report when provider’s gaps in contracts are identified
• Refers all cases that are denied by the payor to the Concurrent Appeal URN or Physician Advisor

List of Typical Skills For an Utilization Review Nurse Resume

Skills for utilization review nurse auditor resume.

• Excellent verbal and written communication, organization and interpersonal skills
• Excellent communication (both written and verbal), organization and interpersonal skills
• Basic computer skills including word processing and spread sheets
• Nursing experience with one (1) year experience in Utilization Management
• Experience in acute long-term care, acute rehabilitation or skilled nursing facilities
• One year of care management, utilization management experience, clinical documentation or clinical auditing experience
• Utilization Review experience at a Managed Care plan or Provider Organization; 5+ years of Healthcare experience
• Develop leadership skills and to serve as a role model for clinical staff
• Demonstrates effective communication with adolescents, adults and older adults

Skills For RN Utilization Review Nurse Bedford, Texas Resume

• Documented experience in collecting, compiling, and performing preliminary analysis of data
• Experience with assisting with Discharge and Transition of Care Planning
• Documented experience assessing and interpreting clinical information from client records
• Documented experience consulting with physicians and other health team members regarding plan of care
• Recent clinical nursing experience in an acute-care hospital setting and/or payer case management
• Reviews and conducting special eligibility validation reviews including SC, Agent Orange, Combat Vet, etc
• Previous experience in an Acute Care, Hospital and/or Clinical setting
• Knowledge and experience in diverse Patient Care settings, including Inpatient Care
• Clinical experience in acute setting

Skills For Utilization Review Nurse Supervisor Resume

• Two or more years of experience in coding or a patient care acute facility, preferably at a tertiary care medical center
• Documented experience collaborating with various disciplines and/or areas within an organization
• Documented experience communicating information with outside entities, patients/families/assigned representatives, and/or staff
• Documented experience reviewing client medical records/charts
• Documented experience communicating information with outside agencies
• Documented experience discussing information with patients, families and/or assigned representatives
• Knowledge of CPT, ICD-10, and/or HCPC codes or coding experience
• Utilization Review experience

Skills For Telephonic Utilization Review Nurse Onsite Resume

• Previous Appeals / Denials experience
• Attention to detail with ability to prioritize, problem solve and multi-task
• Establish priorities, meet deadlines and maintain productivity standards in the management of the work assignment
• Perform utilization reviews to ensure that members receive necessary medical care in a timely and cost-effective manner

Skills For Utilization Review Nurse LPN Resume

• 6+ months of Concurrent / Utilization Review experience
• Demonstrate appropriate network utilization in accordance with regulatory requirements
• Proficient in computer technology and experience with Microsoft Office product Excel, Outlook, Word, Skype, etc
• Experience with clinical applications/systems
• Utilization Review experience for at least 1 year
• Acute care clinical experience
• Ensure full collection of clinical information prior to rendering a decision including contacting hospital providers for additional information as necessary
• Arrange alternative care services and maintain communication with acute long term care, acute rehabilitation or skilled nursing facilities

Skills For Utilization Review Nurse RN Resume

• Reports issues and system barriers to efficient and effective discharge planning to department leadership
• Lifting 50 lbs. (maximum) with frequent lifting and/or carrying of objects weighing up to 25 lbs
• Customer Orientation– establishes and maintains long term customer relationships, building trust and respect by consistently meeting and exceeding expectations
• Participate in company meetings, training activities and continuing education requirements
• Exp working in utilization mngt department (UR, UM, Discharge Planning, CM, Retrospective Review, Concurrent Review)

Skills For Network Utilization Review Nurse Resume

• Two (2) years Utilization Management and/or Hospital discharge planning in the acute care setting within the past four (4) years
• Conduct reviews using clinical assessment and established screening criteria
• Coordinates activities with other medical managmeent departments as needed, including making referrals to Case Managment and Behavioral Health
• Clinical practice in an acute care setting
• Quickly analyze and interpret data and write reports using standard medical terminology
• 1500 Spring Garden St

Skills For Pre-certification / Utilization Review Nurse Resume

• Assist in developing medical policies and procedures that directly impact member utilization of benefits
• 1000 S. Sterling Street
• DCS policies, procedures, and current State Federal and local laws governing AHCCCS/Medicaid health plan operations and requirements
• Proficient in using MS Word, MS Excel, and MS Outlook
• Background working with Medicare and Medicaid population
• BA/BS and nursing diploma. Current employees grandfathered (5/14)

Skills For Associate Utilization Review Nurse, LPN Resume

• Current, unrestricted RN license in the state of Wyoming
• Successful work history in a clinical setting and/or health insurance environment
• Accurately and completely documents in file using standard documentation format(s)
• Coordinate discharge planning to create member’s post-inpatient plan
• Evaluate the need for case management and transition of care services following inpatient stay

Skills For Licensed Utilization Review Nurse Resume

• Coordinate transportation with contracted vendors following inpatient stay
• Facilitate member’s transfers within contract facilities for ongoing inpatient stays
• Escalate cases not meeting criteria to Division PA
• Communicate with physicians regarding patient status, level of care. Medical necessity, utilization of resources, and denials
• Communicate lack of medical necessity and/or responder criteria being met to the facility Case Manager
• Ensure the member is at the appropriate level of care, in the appropriate setting, at the appropriate time through utilization review

List of Typical Responsibilities For an Utilization Review Nurse Resume

Responsibilities for utilization review nurse auditor resume.

• Documented skill in effective communication skills and professional behaviors that promote cooperation and teamwork
• Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software)
• Excellent personal computer skills (MS Outlook, MS Office, Midas, Meditech, OnBase DOS based and other related software) required
• Three to five years clinical experience in a health care environment, with supervisory experience; Managed care experience desired
• Communicates effectively with other health care providers, patients, families, other hospital personnel and visitors
• Position requires candidates with determined and assertive communication skills

Responsibilities For RN Utilization Review Nurse Bedford, Texas Resume

• Behavioral health experience strongly desired
• Facilitates cost effective and quality patient care by effective communication with physicians, providers and members
• Solid understanding of Peer Review Organization criteria and standards, purpose and requirements needed; working knowledge of DRG payment system helpful
• Clinical nursing experience on an orthopedic/neurology nursing unit
• Ensures authorized services are performed in the most cost effective appropriate setting

Responsibilities For Utilization Review Nurse Supervisor Resume

• Educate providers about inpatient and outpatient cost-effectiveness, alternative placement and quality management
• Proven ability to work independently, with attention to detail and accuracy
• Evaluates effectiveness of care and facilitates coordination of care toward specific outcomes criteria
• Worker’s compensation or Occupational Medicine or Rehab experience desirable
• Experience in managed care, case managementd required
• HMO or managed care experience
• Current/valid State of Florida Registered Nurse licensure

Responsibilities For Telephonic Utilization Review Nurse Onsite Resume

• Case Management experience in an acute care setting
• Experience in a leadership role such as a manager, charge nurse, team leader, etc
• Acute care LPN experience
• Initiates the payor appeal process for all concurrent denials following the department guidelines for documentation and escalation
• Perform admission reviews, on in scope populations, utilizing InterQual within 24 hours of admission
• Professional conduct in all situations including clinical department meetings is required
• Documents clinical appropriateness reviews and care management activities in managed care operating systems
• Coordinate discharge planning activities for inpatient level of care services and facilitate referral to care management programs

Responsibilities For Utilization Review Nurse LPN Resume

• Based on case work and departmental reporting, ability to identify and report trends and/or areas of opportunities to department management and peers.
• Understand and investigate billing issues, claims and other plan benefit information.
• Assist with monitoring, inquiries, and audit activities as needed
• Provides insight and direction to management on any compliance concerns regarding products, company policies and procedures and/or client specifications
• Work rotating weekends and holidays
• Provide care coordination of members who are transitioning from one level of care to another

Responsibilities For Utilization Review Nurse RN Resume

• Participates in process performance improvement activities related to utilization management
• LVN with current state licensure
• Plans, implements, and evaluates appropriate health care services in conjunction with the physician treatment plan
• Utilizes clinical skills to assess, plan, implement, coordinate, monitor and evaluate options and services in order to facilitate appropriate healthcare outcomes for members
• Performs prospective, concurrent, and retrospective reviews for inpatient acute care, rehabilitation, referrals, and select outpatient services. Manages own caseload and coordinates all assigned cases

Responsibilities For Network Utilization Review Nurse Resume

• Acts as a resource to others
• Active and unrestricted RN or LVN license in state of New Jersey
• Collaborates with the Case Manager, Social Worker, attending physician, and other healthcare team members to ensure medical appropriateness criteria, to develop an action plan to avert reductions in care or denials and to obtain all payor information that influence discharge planning activities
• Refers all cases that are denied by the payor to the Concurrent Appeal Nurse or Physician Advisor
• Serves as an educational resource for other Case Management staff, other internal departments, physicians, nursing staff and others concerning utilization management strategies essential in meeting the organization's quality, utilization, financial and customer satisfaction objectives
• Validate the patient’s status is correct (Inpatient vs Outpatient) based on physician’s order, take action to correct status if incorrect or no order is present. Document actions

Responsibilities For Pre-certification / Utilization Review Nurse Resume

• Perform initial admission clinical summary reviews within 24 hours or per payor contract on payors with an authorization process
• Perform continued stay clinical summary reviews as per payor contract on payors with an authorization process
• Review and manage concurrent denials per FWD Centralized Utilization Review policy
• Documentation to take place, per HCA and FWD guidelines, in Midas in the Care Enhance Review Manager Enterprise (CERME), Midas Certification Entry, Midas Concurrent Review Entry and the Avoidable Denied Days module
• Registered Nurse, licensed in Massachusetts
• Identify placement settings that offer the lowest level of restriction and greatest level of autonomy for the members based upon medical necessity
• Monitor quality of care and collect and analyze utilization data
• Serve as a resource and liaison between the health plan, behavioral providers, facilities, member and families
• Provide and review member intakes and initial evaluations

Responsibilities For Associate Utilization Review Nurse, LPN Resume

• Comply with performance measures in regards to denials, higher level of care admission certifications and concurrent review timeliness
• Develop and maintain collaborative relationships with providers and educate on levels of care
• Interact with physicians, social workers, providers, case managers, and internal staff to develop discharge plans and oversee their implementation
• Authorize and/or review utilization of mental health and substance abuse services provided in inpatient and intermediate care settings. Assure appropriate levels of care and medical necessity in a manner that supports the recovery process
• Perform quality utilization review through the use of acquired knowledge and application of evidenced based guidelines for Medical Bill Reviews, TX Plans, IMEs, Peer Review reports, correspondences, addendums and/or supplemental reviews
• Utilize evidence-based guidelines (Interqual) and collaborates with hospital case managers, social workers, Primary Care Physicians, attending physicians, internal team and medical directors on a daily basis
• Manage all transitions of care related to a hospital stay through patient interviews, effective planning, and collaboration with facility personnel and client teams to prevent unplanned transitions and re-admissions through proven interventions

Responsibilities For Licensed Utilization Review Nurse Resume

• Knowledgeable about member benefits and assists member to maximize their individual benefit plan
• Facilitate authorizations for post-acute care services or medications
• Review cases for quality of care concerns
• Documents authorizations and case management activities in software applications
• Assumes leadership role in POD/IPA related meetings and shares knowledge and information
• Participates in process improvement activities and all STAR-related initiatives
• Obtains or ensures acquisition of appropriate pre-certifications/authorizations from third party payers and placement to appropriate level of care prior to hospitalization utilizing medical necessity criteria and third party payer guidelines. (30%)
• Obtains or facilitates acquisitions of urgent/emergent authorizations, continued stay authorizations, and authorizations for post-acute services as needed and with compliance with all regulatory and contractual requirements. (30%)

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Career Advice > Job Search > Resumes and Cover Letters > Utilization Review Nurse Resume Writing Tips and Sample

Utilization Review Nurse Resume Writing Tips and Sample

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As a utilization review nurse , you’re a silent architect of healthcare, working behind the scenes to ensure resources are used efficiently and patients receive the care they deserve. These nurses are all about finding that perfect balance between resourcefulness and top-notch care, nurturing the hospital’s sustainable growth, and ensuring continuous improvement in patient care. Note that this position is often available as a remote job .

In order to get into this field, you need a strong utilization review nurse resume and cover letter . A great resume is key to standing out and earning the opportunity for an interview . Don’t forget to check out our resume sample for an extra boost of inspiration.

Tips for Writing Utilization Nurse Resumes

1. prioritize important information.

Have you ever heard about the elevator pitch ? If you were to meet the employer of your dreams in an elevator and only had 30 seconds to showcase your qualifications, what would you say? Think about what sets you apart and make it stand out. Employers scanning through hundreds of resumes won’t have time to uncover your hidden talents in the sea of words. Put your strengths in your resume summary to get the reader’s attention.

2. Quantify Your Experience

It’s beneficial to back up everything you say in your resume with numbers. Saying, “I am an exceptional nurse,” is less informative than stating, “I am a registered nurse with 10 years of experience.” Therefore, support statements with concrete evidence whenever possible. How many years of experience do you have? What is your typical patient load? How many times have you been promoted?

3. Use Similar Wording

Here’s the deal — many companies use computer programs to scan resumes for matching keywords. If you don’t pass that screening, the hiring manager may not even see your resume. To pass this test, customize your resume by using keywords from the job posting. If they’re seeking a utilization review nurse, stick to the term “utilization review,” not “UR nurse.”

4. Personalize Your Resume

Many people think resumes are generic — you create one and mass-send it to all employers out there. But the truth is, generic resumes often go unnoticed. Use those keywords we talked about to customize your resume for each job by adding a personal touch — small adjustments can make a big difference.

Utilization Review Nurse Resume Sample

Dinah roven, rn, hum.

Mountain Street, CA | [email protected] | 444-444-4444

Dedicated and skilled utilization review nurse with over 10 years of experience. Proven track record of efficiently managing and optimizing healthcare resources to ensure quality patient care.

Key Qualifications

• Proven track record in utilization review and case management.
• Clinical expertise as a registered nurse in acute care and med-surg settings.
• In-depth understanding of healthcare regulations and compliance, and proficient in insurance guidelines and reimbursement processes.
• Proficient in working with EHR systems to maintain accurate and detailed patient records.

Mountain University , San Diego, CA, 20XX

Bachelor of Science in Nursing

Professional Experience

Reputable Hospital, Utilization Review Nurse, 20XX–present

• Conducted comprehensive reviews of medical records to assess the appropriateness and necessity of healthcare services.
• Evaluate medical documentation for compliance with regulatory requirements and insurance guidelines.
• Develop and implement care plans based on individual patient needs and available resources.
• Provide recommendations for improving care delivery processes and cost-effectiveness.

Great Hospital, Float Pool Nurse, 20XX–20XX

• Provided expert care to patients in the 150-bed critical care hospital, managing a high caseload.
• Worked in various departments, including medical-surgical, critical care, and emergency.
• Administered life-saving interventions, such as advanced cardiac life support (ACLS) and trauma care.
• Maintained accurate and detailed medical records in compliance with regulatory standards.
• Utilization review and case management
• Clinical assessment and documentation
• Healthcare regulations and compliance
• Strong analytical and problem-solving skills
• Language comprehension: English, Russian, and German
• Software proficiency: Cortex, PowerChart, Epic, Cerner, WebPT

Certifications and Licenses

• Basic life support (BLS)
• Advanced cardiovascular life support (ACLS)
• Registered nurse (RN)
• Health utilization management (HUM)

Utilization Review Nurse Salary

Wondering what utilization review nurses typically earn? The average salary for a utilization review RN in the U.S. is $90,700 per year.

Looking for the highest-paying states for nurses? These states have some of the most competitive salaries in the country:

Ready to Use Your Utilization Review Nurse Resume?

Well done! You’ve conquered the challenges of becoming a nurse and writing a top-notch resume. Now, let IntelyCare help with the rest. Explore the latest utilization review nurse jobs and find the ones that match your skills and interests.

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Utilization Review Nurse Resume Example & Writing Guide

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Utilization review nurse resume sample, professional summary.

Diligent Utilization Review Nurse with 5 years of experience reviewing medical records to ensure compliance with insurance standards, while promoting the most effective use of healthcare resources. Demonstrated ability to communicate with interdisciplinary healthcare teams to develop and implement care plans that meet patient needs, improve outcomes and reduce costs.

Utilization Review Nurse

ABC Healthcare, Anytown USA

May 2020 - Present

• Conducted utilization review of medical records for inpatient and outpatient services to assess and evaluate quality and effectiveness of care
• Collaborated with interdisciplinary healthcare teams to create and implement care plans that meet patient needs, improve outcomes and reduce costs
• Communicated with insurance providers to confirm approvals, resolve denials, and ensure appropriate patient care
• Educated healthcare providers on utilization management procedures, compliance with insurance standards, and medical necessity criteria

Registered Nurse

XYZ Hospital, Anytown USA

August 2015 - May 2020

• Monitored and assessed patient conditions, administered medications, and assisted with activities of daily living
• Collaborated with interdisciplinary healthcare teams to develop and implement care plans that meet patient needs and improve outcomes
• Educated patients and families on discharge instructions and self-care to support optimal recovery
• Documented patient care and outcomes in electronic health records

Bachelor of Science in Nursing

State University, Anytown USA

Graduated May 2015

Avoid Personal Pronouns

Your resume is a formal document. Avoid using personal pronouns like 'I', 'me', or 'my'. Instead, start your sentences with verbs.

Utilization Review Nurse Resume Writing Guide

Introduction:.

If you are looking to apply for the position of a utilization review nurse, then it is important to have a well-crafted resume that highlights your skills, education, and experience. This type of nursing job is competitive, so putting together the best résumé possible is essential in order to stand out from other applicants.

1. Create a Professional Summary:

The first section of your resume should be a professional summary that outlines your skills, experience, and career objective. Keep this section brief, but make sure to include any relevant information that will help you stand out from other applicants.

• Highlight your nursing qualifications and certifications
• Include your areas of expertise
• Outline any relevant work experience
• Explain your goals and what makes you the ideal candidate for the job

2. List your Professional Experience:

The next section of your resume should list your professional experience. This includes your work history as a utilization review nurse, or any other similar nursing experience that would be relevant to the job. Be sure to include the following:

• The name of your previous employer and job title
• Your start and end dates of employment
• Key responsibilities and duties for each job
• Any relevant achievements or accomplishments

3. Highlight your Skills:

List your skills in a separate section of your resume. Utilization review nursing requires a blend of skills and knowledge, so be sure to highlight the ones that make you an excellent candidate:

• Strong analytical and critical thinking skills
• Effective communication skills
• Attention to detail and organizational skills
• Good time management skills to work under strict deadlines
• Ability to work both independently and as part of a team
• Knowledge of electronic medical records (EMRs) and medical terminology
• Familiarity with CMS guidelines, medical coding, and regulations

4. Include your Education and Certifications:

The final section of your resume should list your education and relevant certifications. This should include:

• The name of the universities or institutions you have attended
• Your degree type and major
• Your GPA (if you are a recent graduate)
• Any relevant certifications that you have received, such as Certified Professional Utilization Review Nurse (CPUR) or Certification in Healthcare Quality (CHC)

Conclusion:

A well-written resume is essential for getting noticed by hiring managers and landing a job as a utilization review nurse. Highlighting your skills and experience using the tips outlined above, will help you create a compelling resume that showcases your professional strengths and makes you stand out from other candidates.

Common Resume Writing Mistake

Listing duties, not accomplishments.

Your resume should highlight your accomplishments, not just your job duties. Highlighting your achievements showcases the value you could bring to a new role.

Resume Examples You May Interested

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Utilization Review Nurse Resume Samples

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. The duties listed on the Utilization Review Nurse Resume are – evaluating present condition of the patient , assessing the patient status , verifying the health care costs and policies are adhered to properly, referring patient case to appropriate Doctor , reviewing the insurance policy of the patient, getting the approval of the Doctor before starting a treatment plan .

Utilization Review Nurses need a certain amount of skills and qualifications to reach this post, and such include – patience to deal with distressing and difficult patients, good knowledge about medical claims and insurance claims, knowledge of hospital procedures and nursing administration; and patient case management experience. 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.

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• Utilization Review Nurse

Utilization Review Nurse Resume

Summary : Dedicated registered nurse (RN) with specialty experience in cardiac/medical surgical nursing. Developed a strong knowledge of cardiac nursing. Reliable, an ethical healthcare provider with the ability to stay calm and intervene during crises, and to collaborate on multidisciplinary teams.

Skills : Medicare, Utilization Review, Prior Authorization, Emergency Room Nursing, Air and Ground Transport Nursing, BLS CPR, Critical Care Nursing, Flight Nursing.

Description :

• Responsible for collaborating with healthcare providers and members to promote quality member outcomes, to optimize member benefits, and to promote effective use of resources.
• Appropriateness of treatment setting by utilizing the applicable medical policy and industry standards, accurately interpreting benefits.
• Managed care products, and steering members to appropriate providers, programs or community resources.
• Applies clinical knowledge to work with facilities and providers for care coordination.
• Works with medical directors in interpreting appropriateness of care and accurate claims payment.
• Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria.
• Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract.
• Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost-effective care throughout the medical management process.

Utilization Review Nurse-RN Resume

Headline : Proven record of reliability and responsibility. Strong analytical skills, capable of assessing conditions and implementing appropriate intervention. Resourceful problem solver capable of implementing solutions to complex problems. Relate well to people from a variety of cultures.

Skills : Medical Front Office, Microsoft Office, Excellent Organizational Skills, Excellent Interpersonal Communication Skills.

• Authorizing cases according to approved criteria across the continuum of care to ensure a positive patient outcome.
• Directly responsible for reviewing pre-certification requests, performing inpatient and outpatient reviews, and obtaining, reviewing.
• Maintain knowledge of policy and procedure manual for medical/behavioral health services requiring certification including.
• Apply excellent ability to determine the medical necessity and appropriateness of care using established criteria.
• Refer potential high-risk cases which will benefit from case management services to the case management team.
• Charged with assessing the social, economic, environmental, and emotional factors that interfere with patient and family adjustment to illness and treatment.
• Interface with multidisciplinary staff to identify social factors impacting member illness and treatment.
• Identify and obtain needed community resources and provide feedback to external agencies on cases as necessary.

Utilization Review Nurse I Resume

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. Possess special sensitivity to meeting diverse needs in varied situations.

Skills : Word, Excel, Powerpoint, Strong Analytical Skills, Communication Skills, Medical Terminology.

• Perform review activities for procedures that require preauthorization and Issue approvals for studies that meet specified guidelines. 
• Documents appropriate clinical information into the prior authorization system.
• Participates in on-going training programs to ensure quality performance and compliance with guidelines.
• Maintains a safe, comfortable and therapeutic environment for patients and families in accordance with hospital standard.
• Promotes a positive work environment as evidenced by Demonstrating a professional, supportive attitude for the unit staff, Being receptive and responsive to new ideas.
• Participates in the unit's continuous quality improvement plan to improve organizational performance.
• Maintains established departmental policies and procedures, objectives, performance improvement program, safety, environmental and infection control standards.
• Assists in cost containment through the appropriate ordering and conserving of supplies and equipment.

Utilization Review Nurse-Case Manager Resume

Headline : Experienced RN in areas such as ER, ICU, Ambulance transport, Flight Nursing, Occupational Health, Case Management, Utilization Review for private and Medicare insurance plans. Open to new opportunities and roles.

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.

• Collected in-depth information regarding a patients clinical history, prognosis, treatment plan, response to treatment, access to care, learning needs, and financial constraints.
• Conducted an on-going assessment of the case and discharge an individual from case management services when the optimum status has been achieved.
• Screens for cases which do not meet the client-specific guidelines, i.e.  Physician-developed criteria, guidelines and refers them to the Medical Panel accordingly.
• Establishes a quality check date using client-specific guidelines.
• Utilizes nursing experience and judgment in addition to the client-specific guidelines when determining medical necessity and quality check dates.
• Performs accurate and complete verification of eligibility, benefits, and coverage and apply this information to the pre-certification.
• Performed continuous review of claim trends and issues to identify additional provider/patient education needs.

Utilization Review Nurse II Resume

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.

Skills : Utilization Review, Case Management, Customer Service, Nursing.

• Responsible for referring to complex clinical and medical procedure request to the medical director for review.
• Maintained confidentially and compliance adhering to Health Insurance Portability and Accountability Act (HIPPA) guidelines when reviewing medical documentation.
• Requesting clinical information, or providing Utilization Review determinations in written or verbal format.
• Worked independently processing preauthorization request by utilizing critical thinking skills, excellent communications skills, leadership skills, and organizational skills.
• Proficiently established positive and effective work relationships with co-workers, adjustors, providers, and nonmedical staff.
• Met and exceed accuracy and quality standards efficiently multitasking and triaging caseload.
• Process and review clinical documentation for the purpose of utilization review and precertification/preauthorization determinations.

Utilization Review Nurse-Temp Resume

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 : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint.

• Identify, monitor and evaluate concurrent care of all hospitalized enrollees.
• When appropriate, recommend alternatives to traditional health care to medical directors, network physicians, or non-participating physicians.
• Identify the primary care nurse in the hospital and monitored critical pathways, as applicable.
• Provide and maintain an open system of communication and feedback between the enrollee, hospital, and other levels of care in the community.
• Included information with payor and providers to ensure continuity and efficiency of care.
• Participate in or initiate conferences with the physician, social worker, and other relevant health care team members regarding post-hospital care of patients.
• Track patient progress and care received to identify deviations from accepted care standards.
• Coordinate coverage for rental or purchase of durable medical equipment and records details of these interactions and approve claims for payment.

Jr. Utilization Review Nurse Resume

Headline : Seeking to work with a company that offers high standards of care for patients. Placing the patients needs first. To be part of a team to develop business by building relationships with physicians, case managers, social workers, and discharge planners.

Skills : BLS, Group Management, Reliability, Decision-Making Skills.

• Coordinated mental health services with clinics, specialized units, affiliated private agencies, and available community resources.
• Participated in the development of policies, standards, and guidelines to oversee the performance of agencies contracted to provide mental health treatment statewide.
• Provided project management and participated in onsite clinical record audits to determine contract compliance.
• Compiled data, developed statistical analyses and prepared reports for monitoring in-network private physicians' offices and treatment clinics.
• Responsible for sensitive investigations related to reported incidents and/or complaints initiated by and personal requests from state officials.
• Completed full investigations by reporting findings to the appropriate state, city, or regulatory agencies.
• Concluded investigations by sending personal correspondence to the initiator of complaint or incident indicating what findings could be released.

Objective : 3 years as a Registered Nurse with experience in the clinical setting, case management, care transitions, and utilization review. Having management experience in sub-prime lending, consistently recognized as a top performer.

Skills : Managed Care, Nursing, Marketing, Wound Care.

• Promotes and restores patient health by identifying patient care requirements.
• Makes recommendations, documents findings and collaborates with physicians and multidisciplinary team members to provide physical and psychological support.
• Review medical records to determine medical necessity based upon pre-determined Milliman Criteria.
• Discharge Planning and/or Concurrent Obtain member's medical records and work with providers in order to facilitate a safe discharge plan.
• Evaluate requested outpatient services for medical necessity and setting, search for appropriate participating providers and negotiate rates.
• Perform concurrent reviews of clinical information to determine if the member is receiving appropriate care in the most appropriate setting.
• Adhere to standards of care in order to meet governing agency regulations and assure the patients quality of care.

Utilization Review Nurse-Clinical Resume

Summary : 32+ years of vast experience in core measures concurrent review/utilization management as a Clinical Data Coordinator for the Performance Improvement. Selected to pilot an RN Telecommute program to perform utilization review/concurrent review remotely after proving my dedication, self-motivation, and reliability.

Skills : Excellent Organizational Skills, Excellent Interpersonal Communication Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

• Performs concurrent review of clinical information to determine appropriateness and medical necessity of hospitalization and treatments using Interqual criteria.
• Evaluate the progress of each patient daily and provide updates to insurance providers.
• Follow patients from admission to discharge, ensuring the current level of care is optimal.
• Communicate necessary moves from acute care to a lower level of care at appropriate intervals.
• Collaborate with other professionals to evaluate patients' medical or physical condition and to assess client needs for safe discharge.
• Collaborate with Nurse Navigators to identify frequent hospital readmissions.
• Serve as liaison between patients, families, and health care providers.
• Plan discharge from care facility to home or another care facility.
• Coordinate home care, home hospice, and DME services post-hospital discharge.

Utilization Review Nurse-Part Time Resume

Summary : Utilization Review Nurse with the knowledge and ability to apply various care guidelines while working with physician advisor's to complete reviews within set time frames. Able to work in a fast-paced environment to meet the needs of clients

Skills : Utilization Review, Case Management, Excellent Organizational Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel.

• Review requested medical treatment for medical necessity and medical appropriateness and provide prior authorization for requested treatment.
• Perform reviews of current patient services, and determine medical appropriateness of patient services following evaluation of medical guidelines.
• Make decisions and exercise good judgment in a complex environment.
• Provide telephonic case management of Workers' Compensation claims by facilitating and coordinating all aspects of the injured worker's medical care.
• Maintain a high standard of file documentation to ensure attention to detail and file accuracy.
• Interact with strategic partners to obtain or clarify clinical information.
• Compare clinical information against the appropriate criteria set.
• Authorize medical care and practice medical costs containment skill using the utilization review process.

Utilization Review Nurse-URN Resume

Summary : Energetic, talented, and accomplished Licensed Practical Nurse experience working as LPN and Medical Secretary. Extensive background working with medical records and computer-based scheduling systems. Able to work well in interdisciplinary team environments, coordinating with physicians, and other healthcare staff.

Skills : Strong Clinical Reasoning, Medical Records Review, Excellent Organizational Skills, Excellent Interpersonal Communication Skills.

• Performs concurrent and retrospective review to establish criteria.
• Exercises clinical judgment and objective application Severity of Illness/Intensity of Service criteria in assessing patient medical condition.
• Clinical knowledge of referring to appropriate departments for Children's Special Health Care eligibility.
• Writing, submitting according to departmental policies timely Denials, Dis-enrollments, and referrals to Case Management.
• Assists hospital staff in identifying post-acute care needs in accordance with product insurance benefit availability.
• Evaluation of medical documentation and requesting additional information for transplant eligibility to present to the medical director.
• Processing referral requests for DME, Infusions, Home Health Care, Wound Vacuum's, Subacute Rehabilitation, Inpatient Psych, and Inpatient Rehabilitation.
• Notification to the medical director of all high-cost hospital stays for re-insurance group tracking.

Utilization Review Nurse-LPN Resume

Summary : Excels in relationship building, presentation skills, and psychiatric mental health clinical nursing. 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.

• Served as the liaison between patients, doctors, healthcare providers, and insurance companies.
• In contrast to direct patient care at the bedside, my role was to advocate for all patients enrolled in the healthcare delivery system.
• Worked with a diverse group of patients including the elderly and those who participate in government programs.
• Accountable for Utilization and Quality Management of examination levels, technology, and medication use efficiency, while simultaneously improving patient outcomes.
• Managing expenses and improving the quality of life for persons with long-term conditions.
• Performed a continuous review of claim trends and issues to identify additional provider/patient education needs.
• Reviewed claims for the severity of illness and necessity of service; request supplemental information as needed to finalize claim determination.

Associate Utilization Review Nurse Resume

Summary : An individual with 11 plus years of experience as a Utilization Review Nurse, two years as supervisor of the concurrent review team. Over ten years of experience as a staff nurse and supervisor in a sub-acute and long-term setting.

Skills : Professional Services, Customer Relationship Management, Case Management, Pediatric Experience, Adult experience.

• Responsible for reviewing precertification requests for medical necessity.
• Responsible for obtaining and reviewing daily clinical information for concurrent review, extending the length of stay as medically necessary.
• Responsible for coordinating care to promote improved quality of life and prevent hospitalization.
• Accountable for overseeing a group of nurses in conducting daily task which includes prioritization of authorization notification to providers and case managers.
• Assisting nurses with identified issues by addressing, assessing and analyzing these issues to find a resolution.
• Involved in overseeing and coordinating utilization management ques to meet established performance metrics.
• Performing utilization and concurrent reviews using Milliman criteria while auditing the quality performance of practitioners and facilities.

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.

• Proactively involved in all aspects of Utilization Management including precertification, concurrent review, discharge planning, and clinical case appeals.
• Ensure patient admissions are in compliance with Medicare by using Milliman Care Guidelines.
• Review electronic and paper charts to provide documentation for admission/ stay criteria.
• Confer with internal and external physicians to assess the appropriateness of the level of care.
• Analyze appropriate data to identify trends/problems relating to delays in the delivery of care and patient placement.
• Initiate timely communication with insurance companies to obtain authorization for hospitalizations and advanced imaging to achieve the maximum allowable reimbursement.
• Notify third-party payors, including various state Medicaid programs, via online websites.

Table of Contents

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• Utilization Review Nurse

5 Amazing utilization review nurse Resume Examples (Updated 2023) + Skills & Job Descriptions

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Utilization review nurse: resume samples & writing guide, employment history.

• Participate in quality assurance activities
• Monitor patient care for quality and appropriateness of services
• Develop and maintain utilization review policies and procedures
• Review medical records to ensure that services are medically necessary
• Document all utilization review activities in accordance with regulations
• Facilitate discharge planning and coordinate care transitions
• Collaborate with physicians, case managers, and other members of the healthcare team
• Evaluate the need for continued care and recommend appropriate changes

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• Educate providers and other staff on utilization review processes
• Develop utilization review plans and ensure compliance with regulations
• Verify insurance coverage and authorization for services

Professional Summary

• Provide clinical expertise in the review of medical services
• Perform concurrent and retrospective review of medical services
• Analyze and interpret utilization data to identify trends and cost savings opportunities
• Communicate findings and recommendations to appropriate parties

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Table of Content

• Introduction
• Resume Samples & Writing Guide
• Resume Example 1
• Resume Example 2
• Resume Example 3
• Resume Example 4
• Resume Example 5
• Jobs Description
• Jobs Skills
• Technical Skills
• Soft Skills
• How to Improve Your Resume
• How to Optimize Your Resume
• Cover Letter Example

utilization review nurse Job Descriptions; Explained

If you're applying for an utilization review nurse position, it's important to tailor your resume to the specific job requirements in order to differentiate yourself from other candidates. Including accurate and relevant information that directly aligns with the job description can greatly increase your chances of securing an interview with potential employers. When crafting your resume, be sure to use action verbs and a clear, concise format to highlight your relevant skills and experience. Remember, the job description is your first opportunity to make an impression on recruiters, so pay close attention to the details and make sure you're presenting yourself in the best possible light.

utilization review nurse

• Review individual records and conduct utilization reviews for precertification, continued stay and discharge.

utilization review nurse Job Skills

For an utilization review nurse position, your job skills are a key factor in demonstrating your value to the company and showing recruiters that you're the ight fit for the role. It's important to be specific when highlighting your skills and ensure that they are directly aligned with the job requirements, as this can greatly improve your chances of being hired. By showcasing your relevant skills and experience, you can make a compelling case for why you're the best candidate for the job.

How to include technical skills in your resume:

Technical skills are a set of specialized abilities and knowledge required to perform a particular job effectively. Some examples of technical skills are data analysis, project management, software proficiency, and programming languages, to name a few. Add the technical skills that will get hired in your career field with our simple-to-use resume builder. Select your desired resume template, once you reach the skills section of the builder, manually write in the skill or simply click on "Add more skills". This will automatically generate the best skills for your career field, choose your skill level, and hit "Save & Next."

• Medical Terminology
• Clinical Documentation
• ICD-10 Coding
• Medical Record Review
• Clinical Assessment
• Utilization Management
• Quality Assurance
• Disease Management
• HIPAA Compliance
• Chart Auditing
• Computer Proficiency
• Regulatory Compliance
• Risk Management
• Healthcare Regulations
• Medical Billing
• Claims Processing
• Patient Advocacy
• Healthcare Reimbursement
• Insurance Verification.

How to include soft skills in your resume:

Soft skills are non-technical skills that relate to how you work and that can be used in any job. Including soft skills such as time management, creative thinking, teamwork, and conflict resolution demonstrate your problem-solving abilities and show that you navigate challenges and changes in the workplace efficiently. Add competitive soft skills to make your resume stand-out to recruiters! Simply select your preferred resume template in the skills section, enter the skills manually or use the "Add more skills" option. Our resume builder will generate the most relevant soft skills for your career path. Choose your proficiency level for each skill, and then click "Save & Next" to proceed to the next section.

• Communication
• Interpersonal
• Time Management
• Problem Solving
• Decision Making
• Critical Thinking
• Adaptability
• Organization
• Public Speaking
• Negotiation
• Conflict Resolution
• Attention to Detail
• Self-Motivation
• Stress Management
• Collaboration
• Strategic Thinking
• Emotional Intelligence
• Flexibility
• Reliability
• Professionalism
• Computer Literacy
• Data Analysis
• Project Management
• Customer Service
• Presentation
• Written Communication
• Social Media
• Troubleshooting
• Supervisory
• Database Management
• Documentation
• Financial Management
• Visualization
• Business Acumen
• Process Improvement
• Relationship Management.

How to Improve Your utilization review nurse Resume

Navigating resume pitfalls can mean the difference between landing an interview or not. Missing job descriptions or unexplained work history gaps can cause recruiters to hesitate. Let's not even talk about the impact of bad grammar, and forgetting your contact info could leave your potential employer hanging. Aim to be comprehensive, concise, and accurate.

Unexplained Year Gaps and Missing Job Experiences are a No-no

Gaps in your resume can prevent recruiters from hiring you if you don't explain them..

• It's okay to have gaps in your work experience but always offer a valid explanation instead of just hiding it.
• Use the gap to talk about positive attributes or additional skills you've learned.
• Be honest and straightforward about the gap and explain it using a professional summary.

How to Optimize Your utilization review nurse Resume

Keep an eye out for these resume traps. Neglecting to detail your job roles or explain gaps in your career can lead to unnecessary doubts. Grammar blunders can reflect negatively on you, and without contact information, how can employers reach you? Be meticulous and complete.

• Facilitate discharge planing, and coordiante care transtions.
• Perform concurrent, and retrospective review of medical servies.
• Verfiy insurance coverage, and authoriztion for servies.
• Perform concurrent and retrospectiv review of medical services
• Educate providers and other staff on utilizaiton review processes
• Proivde clinical expertise in the review of medical services
• Evaluate the need for continued care, and recommend appropriate changs.
• Facillitate discharge planning, and co-ordinate care transitions.
• Develop utilisation review plans, and ensurre compliance with regulatons.

Avoid Spelling Mistakes and Include your Contact Information

Missing contact information prevents recruiters from understanding you're the best fit for the position..

• Make sure you're not missing contact information on your resume. That should include your full name, telephone number and email address.
• Make sure to use a professional email address as part of your contact information.
• Highlight your contact information and double check that everything is accurate to help recruiters get in touch with you.

utilization review nurse Cover Letter Example

A cover letter can be a valuable addition to your job application when applying for an utilization review nurse position. Cover letters provide a concise summary of your qualifications, skills, and experience, also it also gives you an opportunity to explain why you're the best fit for the job. Crafting a cover letter that showcases your relevant experience and enthusiasm for the Accounts Payable role can significantly improve your chances of securing an interview.

To the Hiring Team at NYU Langone Health

I am excited to apply for the Chief Utilization Review Nurse position at NYU Langone Health. As a highly skilled Utilization Review Nurse with 7 years of experience in the Medical field, I am confident that I can contribute significantly to your organization.

My life experiences have taught me the importance of hard work, dedication, and collaboration. Whether it was on the work, or just personally, I have always been committed to pursuing my goals with passion and tenacity. I am confident that throughout all of these years I have gained the skills and expertise necessary to succeed in this role and be a great asset for NYU Langone Health. I am eager to join a team that shares my values and work towards a common goal.

I cannot stress enough how thrilled I am about the chance to join a team of like-minded individuals who share my values and passion for this amazing field. Thank you for considering my application and I hope for the chance to work together.

Showcase your most significant accomplishments and qualifications with this cover letter. Personalize this cover letter in just few minutes with our user-friendly tool!

Related Resumes & Cover Letters

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Utilization Review Nurse resume examples for 2024

A strong utilization review nurse resume should highlight the ability to verify medical records and authorization requests, conduct clinical reviews, and manage patient care documentation. It's also important to showcase experience with various medical codes and criteria, such as Interqual and CPT. As seen in the examples, a utilization review nurse resume should also demonstrate the ability to interact with patients, medical professionals, and insurance providers, while maintaining knowledge of community resources and HIPAA regulations.

Utilization Review Nurse resume example

How to format your utilization review nurse resume:.

• Use the job title 'Utilization Review Nurse' on your resume to match the application.
• Tailor your work experience to emphasize achievements that demonstrate your ability to determine medical necessity, utilize InterQual criteria, and improve processes.
• Limit your resume to one page, focusing on relevant experience and accomplishments that showcase your expertise as a Utilization Review Nurse.

Choose from 10+ customizable utilization review nurse resume templates

Choose from a variety of easy-to-use utilization review nurse resume templates and get expert advice from Zippia’s AI resume writer along the way. Using pre-approved templates, you can rest assured that the structure and format of your utilization review nurse resume is top notch. Choose a template with the colors, fonts & text sizes that are appropriate for your industry.

Utilization Review Nurse resume format and sections

1. add contact information to your utilization review nurse resume.

Utilization Review Nurse Resume Contact Information Example # 1

Montgomery, AL 36043| 333-111-2222 | [email protected]

2. Add relevant education to your utilization review nurse resume

Your resume's education section should include:

• The name of your school
• The date you graduated ( Month, Year or Year are both appropriate)
• The name of your degree

If you graduated more than 15 years ago, you should consider dropping your graduation date to avoid age discrimination.

Optional subsections for your education section include:

• Academic awards (Dean's List, Latin honors, etc. )
• GPA (if you're a recent graduate and your GPA was 3.5+)
• Extra certifications
• Academic projects (thesis, dissertation, etc. )

Other tips to consider when writing your education section include:

• If you're a recent graduate, you might opt to place your education section above your experience section
• The more work experience you get, the shorter your education section should be
• List your education in reverse chronological order, with your most recent and high-ranking degrees first
• If you haven't graduated yet, you can include "Expected graduation date" to the entry for that school

Check More About Utilization Review Nurse Education

Utilization Review Nurse Resume Relevant Education Example # 1

Master's Degree In Nursing 2000 - 2001

Grand Canyon University Phoenix, AZ

Utilization Review Nurse Resume Relevant Education Example # 2

Bachelor's Degree In Nursing 2003 - 2006

Miami Dade College Miami, FL

3. Next, create a utilization review nurse skills section on your resume

Your resume's skills section should include the most important keywords from the job description, as long as you actually have those skills. If you haven't started your job search yet, you can look over resumes to get an idea of what skills are the most important.

Here are some tips to keep in mind when writing your resume's skills section:

• Include 6-12 skills, in bullet point form
• List mostly hard skills ; soft skills are hard to test
• Emphasize the skills that are most important for the job

Hard skills are generally more important to hiring managers because they relate to on-the-job knowledge and specific experience with a certain technology or process.

Soft skills are also valuable, as they're highly transferable and make you a great person to work alongside, but they're impossible to prove on a resume.

Example of skills to include on an utilization review nurse resume

The branch of secondary healthcare which is responsible for giving short-term care to patients recovering from severe injuries or urgent medical problems is known as acute care. Acute care comprises multiple domains like; emergency care, urgent care, short-term stabilization, pre-hospital care, critical care, and trauma care.

Another name for utilization review is utilization management. It is the process of ensuring that healthcare services are used in a suitable manner. Utilization review is a critical component of adding value to the health care system. Mostly, UR is carried out by healthcare insurance companies, but hospitals and other healthcare providers also perform the process. Utilization review has three types of assessment namely: concurrent, prospective, and retrospective.

Community resources are a set of resources that are used in the day to day life of people which improves their lifestyle in some way. People, sites or houses, and population assistance can come under the services offered by community resources.

Clinical knowledge is defined as the complete body of information about diseases, pathology, treatments, drugs, mechanisms, pathogenesis, therapies, interactions, contraindications, and interpretation of lab tests and reports which is helpful in devising a diagnosis and treatment plan for a given patient.

Patient care entails the diagnosis, recovery, and control of sickness as well as the maintenance of physical and emotional well-being through the use of healthcare providers' services. Patient care is described as services provided to patients by health practitioners or non-professionals under guidance.

CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.

Top Skills for a Utilization Review Nurse

• Medical Necessity , 9.0%
• Patients , 7.4%
• Acute Care , 7.4%
• Discharge Planning , 7.2%
• Other Skills , 69.0%

4. List your utilization review nurse experience

The most important part of any resume for a utilization review nurse is the experience section. Recruiters and hiring managers expect to see your experience listed in reverse chronological order, meaning that you should begin with your most recent experience and then work backwards.

Don't just list your job duties below each job entry. Instead, make sure most of your bullet points discuss impressive achievements from your past positions. Whenever you can, use numbers to contextualize your accomplishments for the hiring manager reading your resume.

It's okay if you can't include exact percentages or dollar figures. There's a big difference even between saying "Managed a team of utilization review nurses" and "Managed a team of 6 utilization review nurses over a 9-month project. "

Most importantly, make sure that the experience you include is relevant to the job you're applying for. Use the job description to ensure that each bullet point on your resume is appropriate and helpful.

• Facilitated delivery of evidence-based nursing care in the Northern Virginia Region.
• Researched/recommended alternative items to contracts.
• Promoted learning environment for all team members and maintained standards of efficiency and cost effectiveness.
• Led training for new hire nurses to the phone triage call center for monthly hires between 2-12 nurses.
• Assigned all UM NCQA standards for internal auditing and preparation of our NCQA 3rd submission for accreditation.
• Managed three NIH funded studies including development and design of educational interventions for patients and caregivers.
• Provided HIV and STD counseling, testing, and treatment.
• Reviewed protocols submitted to OCR to determine if a PRA was required.
• Reviewed study protocols for financial and resource feasibility.
• Analyzed VINCI database to determine progression of diabetes.
• Established successful account relationships with physicians and pharmacist; building rapport and maintaining consistent communication.
• Ensured HIPAA compliance and also, schedule doctors appointments for patients.
• Communicated residents' concerns with doctors and facilitated resolution of these issues.
• Provided excellence in customer service with internal and external customers resulting in heightened customer satisfaction.
• Answered multiple phone lines and triage patient calls.
• Assisted the Investigator in the conduct of research in accordance with the statement of Investigator (Form FDA 1572/Investigator Agreement).
• Obtained clinical information using IRB protocol standards and consulted with the principal investigator regarding the study.
• Worked with investigators and coordinators in completing regulatory files.
• Mentored a team of seven Innovation Project Managers located across the country.
• Acted as Field Clinical Engineer at implant procedures and follow-up visits in the absence of the assigned FCE.

5. Highlight utilization review nurse certifications on your resume

Specific utilization review nurse certifications can be a powerful tool to show employers you've developed the appropriate skills.

If you have any of these certifications, make sure to put them on your utilization review nurse resume:

• Certified Case Manager (ACM)
• Legal Nurse Consultant Certified (LNCC)
• Medical Assistant
• Certified Nurse Assistant (CNA)
• Certified Nurse Technician (CNT)
• Certified Managed Care Nurse (CMCN)
• Certified Gastroenterology Licensed Vocational/Practical Nurse (LPN/LVN)
• Medical-Surgical Nursing (RN-BC)
• Certified Nurse Educator (CNE)
• Family Nurse Practitioner

6. Finally, add an utilization review nurse resume summary or objective statement

A resume summary statement consists of 1-3 sentences at the top of your utilization review nurse resume that quickly summarizes who you are and what you have to offer. The summary statement should include your job title, years of experience (if it's 3+), and an impressive accomplishment, if you have space for it.

Remember to emphasize skills and experiences that feature in the job description.

Common utilization review nurse resume skills

• Medical Necessity
• Discharge Planning
• Utilization Management
• Utilization Review
• Community Resources
• Outpatient Services
• Clinical Knowledge
• Home Health
• Patient Care
• Medical Directors
• Clinical Judgment
• Medical Care
• Clinical Review
• Chart Review
• Proactive Planning
• Social Work
• Concurrent Review
• Health Care Services
• Inpatient Admissions
• Health Plan
• Interqual Criteria
• Retrospective Reviews
• Clinical Documentation
• Excellent Interpersonal
• Data Collection
• Medical Services
• Rehabilitation
• Strong Computer
• Medical Policy
• Physician Review
• Medical Claims
• Clinical Criteria
• Clinical Guidelines

Utilization Review Nurse Jobs

Links to help optimize your utilization review nurse resume.

• How To Write A Resume
• List Of Skills For Your Resume
• How To Write A Resume Summary Statement
• Action Words For Your Resume
• How To List References On Your Resume

Utilization Review Nurse resume FAQs

What are the responsibilities of a utilization review nurse, what is utilization in nursing, what nursing skills should be listed on a resume, search for utilization review nurse jobs.

Updated June 25, 2024

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The Zippia Research Team has spent countless hours reviewing resumes, job postings, and government data to determine what goes into getting a job in each phase of life. Professional writers and data scientists comprise the Zippia Research Team.

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Utilization Review Nurse Resume Examples

Writing a great utilization review nurse resume is important because it is one of the first things a potential employer will see when they are considering you for a position. It is your opportunity to make a good first impression and sell yourself as the best candidate for the job.

Create your resume Select from 7 professional resume templates

If you're looking for inspiration when it comes to drafting your own utilization review nurse resume, look no further than the samples below. These resumes will help you highlight your experience and qualifications in the most effective way possible, giving you the best chance of landing the utilization review nurse job you're after.

or download as PDF

Essential Components of a Utilization Review Nurse Resume

A well-crafted resume is a critical tool for a Utilization Review Nurse, highlighting their expertise, experience, and qualifications in the field. It provides employers with a concise overview of the candidate's capabilities, demonstrating their proficiency in delivering quality patient care while effectively managing healthcare expenditures.

An effective resume must include certain key elements that underscore the nurse's proficiency in utilization review and general nursing acumen.

The following sections will delve into the essential components of a Utilization Review Nurse resume, explaining the significance of each and offering guidance on how to optimize them for maximum impact.

1. Contact Information

At the forefront of your resume should be your contact information, as it is the primary means for potential employers to initiate communication. Ensure accuracy and visibility.

Begin with your full name, prominently displayed, followed by your professional title, "Utilization Review Nurse." Include your city and state if relevant, and provide a professional-sounding email address and phone number. If applicable, add links to your LinkedIn profile or digital portfolio to showcase your professional background.

• Place these details at the top of your resume for easy access.
• Double-check for accuracy to avoid missing potential opportunities.

2. Professional Summary or Objective Statement

The Professional Summary or Objective Statement serves as your professional introduction, succinctly presenting your skills, experiences, and career goals. Tailor this section to the Utilization Review Nurse role, emphasizing your expertise in clinical review, case management, healthcare policies, patient advocacy, and medical documentation.

A compelling summary or objective can capture an employer's attention by illustrating your potential contributions to their organization. Whether you have extensive experience or are new to the field with transferable skills, this section should position you as the ideal candidate for a Utilization Review Nurse position.

Related : Top Utilization Review Nurse Resume Objective Examples

3. Nursing License and Certification Details

Include your nursing license and any relevant certifications to establish your legal qualification to practice as a nurse. Detail your RN license, any multi-state licenses, and certifications from organizations like the ACMA or CCMC, which underscore your specialization in utilization review.

Highlight additional certifications such as CPHQ or CCS, and mention any in-progress certifications to show your commitment to professional growth.

Ensure all listed licenses and certifications are current and valid to maintain credibility with potential employers.

4. Relevant Work Experience in Utilization Review

Detailing relevant work experience is crucial. Outline your previous roles, emphasizing specific responsibilities and achievements, such as identifying cost-saving measures without compromising patient care quality. Include experience with EHR systems and data analysis software, and quantify your accomplishments to provide a clear picture of your impact.

This section should not only showcase your expertise in utilization review but also suggest how you could enhance efficiency and reduce costs for the employer.

5. Skills and Competencies

The Skills and Competencies section is vital, demonstrating your suitability for the role. List essential skills such as clinical knowledge, analytical abilities, communication proficiency, attention to detail, decision-making, understanding of healthcare laws, computer literacy, time management, interpersonal skills, and ethical practice.

Highlighting these skills can convince potential employers of your fit for the Utilization Review Nurse role.

Related : Utilization Review Nurse Skills: Definition and Examples

6. Education and Training Background

Your educational background is fundamental, showcasing your foundational nursing education and any advanced degrees or specialized training in utilization review. List your degrees, certifications, and any additional training that enhances your qualifications for the role, such as CCM or CPUR certifications.

Include the institutions from which you obtained your qualifications to provide a complete educational history.

7. References or Referees

While not always included on the resume, having a prepared list of references is essential. Select individuals who can attest to your nursing skills and professional character, such as former supervisors or colleagues. Ensure their consent and provide accurate contact information.

Inform your references about the positions you are applying for so they can tailor their recommendations accordingly.

Remember, the right references can significantly influence the hiring decision by endorsing your qualifications and experience.

In summary, a well-prepared list of references is a crucial component of your job application process as a Utilization Review Nurse, even if it is not directly included on your resume.

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Utilization Review Nurse Resume Examples & Guide

Create a standout utilization review nurse resume with our online platform. browse professional templates for all levels and specialties. land your dream role today.

Are you a Utilization Review Nurse looking to create or update your resume? Look no further! Our Utilization Review Nurse Resume Example article provides a comprehensive guide to crafting a standout resume. From formatting and layout to content and language, this example will help you showcase your skills, qualifications, and experience in the best possible light. Get started on creating a winning resume with our helpful example.

We will cover:

• How to write a resume , no matter your industry or job title.
• What to put on a resume to stand out.
• The top skills employers from every industry want to see.
• How to build a resume fast with our professional Resume Builder .
• Why you should use a resume template

What does an Utilization Review Nurse do?

• Review medical records and assess the appropriateness, necessity, and efficiency of healthcare services
• Communicate with healthcare providers to gather additional information as needed
• Evaluate the patient's treatment plan and identify any potential gaps in care
• Ensure that patients receive the most effective and cost-efficient care
• Collaborate with insurance companies to determine coverage and reimbursement for healthcare services
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What are some responsibilities of an Utilization Review Nurse?

• Reviewing medical records to ensure appropriate use of resources
• Assessing the necessity and appropriateness of medical services
• Collaborating with healthcare providers to develop and implement care plans
• Evaluating patient outcomes and recommending changes to treatment plans if needed
• Adhering to regulations and standards related to healthcare utilization
• Communicating with insurance companies to justify medical necessity for certain treatments
• Providing support and education to patients and their families about utilization review processes
• Participating in quality assurance and improvement initiatives

Sample Utilization Review Nurse Resume for Inspiration

Utilization Review Nurse Resume

Name: [Your Name]

Email: [Your Email Address]

Phone Number: [Your Phone Number]

A dedicated and experienced Utilization Review Nurse with a proven track record of efficiently assessing and evaluating patient care plans. Skilled in carrying out comprehensive reviews to ensure that patients receive quality and cost-effective healthcare services. Adept at collaborating with healthcare professionals to optimize patient care and outcomes.

Work Experience

• [Job Title] at [Company Name], [Location] - [Start Date] to [End Date]
• Bachelor of Science in Nursing (BSN) - [University Name], [Location]
• Registered Nurse (RN) Certification - [Certifying Authority]
• Comprehensive assessment
• Utilization review
• Clinical expertise
• Interdisciplinary collaboration
• Healthcare regulations and standards

Certifications

• Registered Nurse (RN)
• Utilization Review Nurse Certification

English - Native proficiency

Spanish - Proficient

Resume tips for Utilization Review Nurse

Creating a perfect, career-launching resume is no easy task. Following general writing rules can help, but it is also smart to get advice tailored to your specific job search. When you’re new to the employment world, you need Utilization Review Nurse resume tips. We collected the best tips from seasoned Utilization Review Nurse - Check out their advice to not only make your writing process easier but also increase your chances of creating a resume that piques the interest of prospective employers.

• Highlight your experience in utilization review and/or case management
• Showcase your knowledge of medical coding and billing procedures
• Emphasize your strong communication and interpersonal skills
• Demonstrate your ability to work independently and as part of a team
• Include any relevant certifications or additional training in utilization review or healthcare management

Utilization Review Nurse Resume Summary Examples

A Utilization Review Nurse Resume Summary or Resume Objective is used to quickly and effectively communicate the candidate's relevant skills, experience, and career goals to potential employers. It offers a concise overview of the candidate's qualifications and can help capture the attention of hiring managers. A well-crafted summary or objective can increase the likelihood of securing an interview and ultimately landing the job. For Example:

• Performed utilization review activities to ensure appropriate medical care and services for patients.
• Reviewed medical records and treatment plans to assess the necessity and efficiency of healthcare services.
• Collaborated with healthcare providers to develop and implement appropriate treatment plans and discharge plans.
• Evaluated the effectiveness of medical care and recommended changes to improve patient outcomes and reduce costs.
• Provided education and support to healthcare teams regarding utilization review practices and procedures.

Build a Strong Experience Section for Your Utilization Review Nurse Resume

Building a strong experience section for your Utilization Review Nurse resume is essential because it showcases your skills, qualifications, and accomplishments in the field. This section gives potential employers a clear understanding of your experience and expertise, making you a more competitive candidate. It also demonstrates your ability to handle the responsibilities of the job, such as conducting utilization reviews and collaborating with a multi-disciplinary team to ensure quality patient care. For Example:

• Conducted utilization reviews for patients to ensure appropriate levels of care and minimize healthcare costs.
• Collaborated with healthcare providers to develop and implement individualized care plans for patients.
• Assessed medical records and treatment plans to determine the necessity and effectiveness of services provided.
• Utilized evidence-based guidelines and criteria to make recommendations for the authorization of medical services.
• Communicated with insurance companies and healthcare professionals to obtain necessary information for utilization reviews.
• Conducted retrospective reviews of medical records to evaluate the appropriateness of care and identify potential quality concerns.
• Provided education and support to patients and their families regarding the utilization review process and available resources.
• Participated in multidisciplinary team meetings to discuss patient care and make recommendations for treatment plans.
• Monitored and documented patient outcomes to evaluate the effectiveness of treatment and identify opportunities for improvement.
• Adhered to regulatory requirements and ethical standards in the performance of utilization review activities.

Utilization Review Nurse resume education example

A Utilization Review Nurse typically needs a Bachelor of Science in Nursing (BSN) degree and a valid nursing license. Some employers may also require additional certifications such as Certified Professional in Healthcare Utilization Management (CCHUM) or Certified Case Manager (CCM). Many UR nurses also pursue advanced degrees such as a Master of Science in Nursing (MSN) or Master of Business Administration (MBA) to advance their career in utilization review. Here is an example of an experience listing suitable for a Utilization Review Nurse resume:

• Master of Science in Nursing, ABC University (2012)
• Bachelor of Science in Nursing, XYZ College (2008)
• Utilization Review Certification, American Case Management Association (2014)

Utilization Review Nurse Skills for a Resume

It is important to add skills for Utilization Review Nurse Resume as these skills demonstrate the candidate's ability to conduct comprehensive patient assessments, review medical records, analyze medical data, and ensure appropriate level of care. Additionally, showcasing skills related to communication, critical thinking, and decision-making can indicate the candidate's capability to collaborate with healthcare professionals and effectively determine the best course of action for patient care. Soft Skills:

• Communication skills
• Critical thinking
• Time management
• Problem solving
• Interpersonal skills
• Organization skills
• Adaptability
• Attention to detail
• Clinical Assessment
• Medical Coding
• Healthcare Regulations
• Data Analysis
• Case Management
• Utilization Review
• Medical Terminology
• Electronic Health Records
• Quality Improvement
• Risk Management

Common Mistakes to Avoid When Writing an Utilization Review Nurse Resume

In this competitive job market, employers receive an average of 180 applications for each open position. To process these resumes, companies often rely on automated applicant tracking systems, which can sift through resumes and eliminate the least qualified applicants. If your resume is among the few that make it past these bots, it must still impress the recruiter or hiring manager. With so many applications coming in, recruiters typically give each resume only 5 seconds of their attention before deciding whether to discard it. Considering this, it's best to avoid including any distracting information on your application that could cause it to be thrown away. To help make sure your resume stands out, review the list below of what you should not include on your job application.

• Not including a cover letter. A cover letter is a great way to explain why you are the best candidate for the job and why you want the position.
• Using too much jargon. Hiring managers do not want to read a resume full of technical terms that they do not understand.
• Omitting important details. Make sure to include your contact information, educational background, job history, and any relevant skills and experiences.
• Using a generic template. Take the time to customize your resume to the job you are applying for. This will show the employer that you are serious about the position.
• Spelling and grammar errors. Always double-check your resume for typos, spelling mistakes, and grammar errors.
• Focusing too much on duties. Make sure to include accomplishments and successes to show the employer that you are a great candidate.
• Including personal information. Avoid including any personal information such as age, marital status, or religious beliefs.

Key takeaways for a Utilization Review Nurse resume

• Strong knowledge of utilization review processes and procedures
• Experience in reviewing and analyzing medical records
• Ability to make cost-effective recommendations for patient care
• Excellent communication and interpersonal skills
• Proficient in using electronic health record systems
• Ability to work collaboratively with multidisciplinary teams
• Proven track record of meeting regulatory and accreditation requirements
• Strong attention to detail and ability to prioritize tasks
• Ability to identify and address potential quality of care issues
• Commitment to maintaining patient confidentiality and ethical standards

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Utilization Management Nurse Resume Samples

The guide to resume tailoring.

Guide the recruiter to the conclusion that you are the best candidate for the utilization management nurse job. It’s actually very simple. Tailor your resume by picking relevant responsibilities from the examples below and then add your accomplishments. This way, you can position yourself in the best way to get hired.

Craft your perfect resume by picking job responsibilities written by professional recruiters

Pick from the thousands of curated job responsibilities used by the leading companies, tailor your resume & cover letter with wording that best fits for each job you apply.

Create a Resume in Minutes with Professional Resume Templates

• Supports the effective prevention and management of denials, including providing requested information as part of the appeal process
• Assists in the identification and reviewing of Potential Quality of Care concerns through concurrent review. Provides backup for Case Manager
• Perform utilization management, utilization review, or concurrent review (on-site of via telephone)
• Enhances professional growth and development through participation in educational programs, current literature, in-service meetings and workshops
• Plan, organize and prioritize assignments to comply with performance standards, corporate goals, and established timelines
• Work as an interdisciplinary team member within Medical Management and across all departments
• Provides clinical support to non-clinical Care Management Coordinators as relates to Prior Authorization requests
• Perform utilization management, utilization review, or concurrent review (on - site or telephonic inpatient care management)
• Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care management)
• Provide explanations and information to others on difficult issues
• Coach, provide feedback, and guide others
• Coach, provide feedback and guide others
• Work with minimal guidance; seeks guidance on only the most complex tasks
• Critical analysis of case manager UM submission with review of supporting tools
• Develop and maintain pre-established review parameters under the direction of the Corizon Medical Director
• Communicate and guide staff and physicians regarding utilization management program development, implementation, evaluation and reporting
• Communicate and document any issues relating to the outpatient/inpatient UM process to the Manager of Utilization Management
• Respond to inquiries by provider/site employees relating to standards of care and best practices
• The UM nurse is responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice
• Recommend improvements to process and outcomes using data analysis tools, logical rules/relations and data elements
• Assist with the data collection and reporting related to the UM outpatient/inpatient process
• Ability to learn quickly and retain complex information
• Strong Utilization skills and knowledge
• Strong attention to detail
• Ability to be professional in all dealings within and outside the company
• Strong computer skills with demonstrated proficiency in word processing, spreadsheet, database, presentation and email applications
• Identifies and recommends opportunities for cost savings and improving the quality of care across the continuum
• Identify appropriate providers and facilities throughout the continuum of care, ensuring that the care is cost effective and of high quality
• Capable of priority setting
• Excellent verbal and written communication skills
• Basic computer and data analysis skills

15 Utilization Management Nurse resume templates

Read our complete resume writing guides

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• Current New York RN license
• 1+ year of experience as a nurse in a hospital setting
• Knowledge of utilization review, evidence-based guidelines, and case management process
• Case management certification preferred

Rn-onsite Utilization Management Nurse Resume Examples & Samples

• This position requires travel to acute care facilities in Flagler County / St. Augustine, FL area. The rest is work at home
• Prior clinical experience preferably in an acute care clinical setting
• Previous experience in utilization management, discharge planning and/or medical case management

Onsite Utilization Management Nurse Liaison Resume Examples & Samples

• This is a patient facing role so a TB test is required if hired
• Education: Associate or Bachelor's degree in Nursing
• Experience with Milliman and Interqual a plus

Onsite Utilization Management Nurse Resume Examples & Samples

• Experience in telephonic and or onsite utilization management conducting concurrent review and discharge planning
• Excellent written and verbal communication skills particularly with providers and members
• Experience with CMS criteria, Milliman and/or InterQual
• Experience working with HMO's
• 2+ years of Utilization Management experience
• Previous Managed Care experience
• Knowledge of Medicaid benefits
• Knowledge of Interqual / Milliman criteria
• New Jersey State Registered Nurse or Licensed Practice Nurse
• Associate's or Bachelor’s degree
• 2-4 years previous Utilization Management/Concurrent Review experience in Managed Care
• 2 years of Medical/Surgical experience
• Systems knowledge – Medical Management Systems
• PC proficiency: MS Office (Word & Excel)

Acute Utilization Management Nurse Resume Examples & Samples

• Examine clinical programs information to identify members for specific case management and / or disease management activities or interventions by utilizing established screening criteria
• Ability to be licensed in multiple states without restrictions
• Valid drivers license and/or dependable transportation necessary (variable by region)

Utilization Management Nurse for the WI Sub-acute Team Resume Examples & Samples

• Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
• Prior experience working in a Skilled Nursing Facility (SNF) a plus
• Previous experience in utilization management, case management, discharge planning and/or home health or rehab
• Associate’s or Bachelor’s Degree (or higher) in Nursing and/or a Health related field OR accredited diploma Nursing school
• Microsoft Office/Suite proficient (Word, Outlook, etc.)
• Solid analytical, critical thinking and problem solving skills
• Working knowledge of principles of Utilization Management
• Basic knowledge of Healthcare Contracts and Benefit Eligibility requirements
• 2+ years of Acute Clinical Care experience
• Current, unrestricted FL Registered nurse (RN) license
• Previous Utilization Management experience in a Managed Care setting
• Experience using nationally accepted criteria (Interqual, Milliman, etc.)

Utilization Management Nurse RN Resume Examples & Samples

• Perform utilization management, utilization review, or concurrent review (on-site or telephonic inpatient care, skilled nursing facility, long term care facility, acute rehabilitation)
• Utilization Management / Utilization Review experience
• Case Management experience
• Knowledge of MCG Criteria
• 2+ years of managed care experience
• 2+ years of clinical care experience

Rn-utilization Management Nurse Resume Examples & Samples

• Performs utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
• Determines medical necessity of each request by applying appropriate medical criteria to first level reviews and utilizing approved evidenced based guidelines/criteria
• Utilizes decision-making and critical-thinking skills in the review and determination of coverage for medically necessary health care services
• Answers Utilization Management directed telephone calls; managing them in a professional and competent manner
• Refers case to a review physician when the treatment request does not meet necessity per guidelines, or when guidelines are not available. Referrals must be made in a timely manner, allowing the review physician time to make appropriate contact with the requesting provider in accordance with departmental policy and within CMS or URAC mandated turn around times
• Reviews, documents, and communicates all utilization review activities and outcomes including, but not limited to, all calls made and received in regard to case communication and all demographic and service group information. Sends appropriate system-generated letters to provider and member
• May provide guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
• Identify and refer all potential quality issues to the Clinical Quality Management Department, and suspected fraud and abuse cases to Compliance Department
• Conducts rate negotiation with non-network providers, utilizing appropriate reimbursement methodologies
• Documents rate negotiation accurately for proper claims adjudication
• Identify and refer potential cases to Disease Management and Case Management
• Current RN license, applicable for practice in the applicable state
• 2 years of experience in managed care OR 5 years of nursing experience
• Strong problem solving and analytical skills
• Proficient in PC software computer skills
• Excellent communication skills both verbal and written skills
• Ability to interact productively with individuals and with multidisciplinary teams
• Possess planning, organizing, conflict resolution, negotiating, and essential interpersonal skills
• Previous Prior Authorization experience
• Utilization Review/Management experience
• ICD-9, CPT coding knowledge/experience
• InterQual or Milliman Knowledge/experience

Tricare Inpatient Utilization Management Nurse Resume Examples & Samples

• Performing care management activities to ensure that patients move through the continuum of care efficiently and safely
• Performing Nurse to Physician interaction to acquire additional clinical information or discuss alternatives to current treatment plan
• Escalating cases to the Medical Director for case discussion or peer-to-peer intervention as appropriate
• Performing anticipatory discharge planning in accordance with the patient's benefits and available alternative resources
• Referring patients to disease management or case management programs
• Assisting with the development of treatment plans
• Works with minimal guidance; seeks guidance on only the most complex tasks
• Works with less structured, more complex issues
• 3 years of clinical experience in an inpatient/acute setting
• Intermediate computer skills - Proficiency with Microsoft Word, Outlook and Internet Explorer, with the ability to navigate a Windows environment
• United States Citizenship
• Ability to obtain favorable adjudication following submission of Department of Defense eQuip Form SF86
• Knowledge of or experience with Milliman Care Guidelines
• Experience in discharge planning or chart review
• 2+ years of experience in a Hospital setting
• Acute or Direct Care experience
• Experience as a Case Manager, Care Coordinator, Concurrent Review nurse, Utilization Review Nurse, or Discharge Planner
• Prior experience with EMRs, Case Management, Utilization / Concurrent Review, Prior Authorization, Care Coordination, & Discharge Planning software tools
• Basic knowledge of Health Care Contracts, Benefit Eligibility requirements, Hospital Structure and Payment Systems
• Working knowledge of Milliman/MCG/CareWebQ
• 3 years of current Pediatric Registered Nurse experience
• Knowledge of Managed Care guidelines and medical insurance operations
• Bachelors of Nursing Degreed
• Experience as a Case Manager, Care Coordinator, Concurrent Review nurse, Utilization Review Nurse, and/or Discharge Planner
• Basic knowledge of Healthcare Contracts, Benefit Eligibility requirements, Hospital structure and Payment Systems
• Working knowledge of Milliman / MCG / CareWebQI
• Prior experience with EMRs, Case Management, Utilization / Concurrent Review, prior Authorization, Care Coordination, and Discharge Planning software tools

Utilization Management Nurse Rn-telecommute Resume Examples & Samples

• Identify solutions to non - standard requests and problems
• 3+ years of experience in an acute care setting
• Knowledge of utilization management, quality improvement, discharge planning with transitions of care
• Possess planning, organizing, conflict resolution, negotiating and interpersonal skills
• MCG certification, if does not have certification, must obtain within 3 months of hire
• Independent problem identification / resolution and decision making skills
• Able to prioritize, plan, and handle multiple tasks / demands simultaneously
• Experience working with Medicare members
• MCG utilization management experience
• Working knowledge of hospice and palliative care
• Graduate degree in related field
• Working knowledge of SNF & LTAC facilities
• Experience using EMR, utilization management and / or prior authorization systems
• Performs concurrent and retrospective reviews on all facility (hospital, skilled nursing facility, and acute rehabilitation) and appropriate home health services. Monitors level and quality of care. Responsible for the proactive management of acutely and chronically ill patients with the objective of improving quality outcomes and decreasing costs. Evaluates and provides feedback to member’s providers regarding a member's discharge plans and available covered services, including identifying alternative levels of care that may be more appropriate
• As part of the hospital prior authorization process, responsible for determining “observational” vs. “acute inpatient” status
• Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning
• Presents facility-patient status updates and addresses barriers to discharge/transition at regularly held concurrent review rounds
• Actively participates in the notification processes that result from the clinical utilization reviews with the facilities. Prepares CMS-compliant notification letters of NON-certified and negotiated days within the established time frames. Reviews all NON-certification files for correct documentation
• Maintains accurate records of all communications
• Monitors utilization reports to assure compliance with reporting and turnaround times
• Addresses care issues with Manager, Vice President and Chief Medical Officer/Medical Director as appropriate
• Coordinates an interdisciplinary approach to support continuity of care
• Provides utilization management, transition coordination, discharge planning, and issuance of all appropriate authorizations for covered services as needed for providers and members
• Coordinates identification and reporting of potential high dollar/utilization cases to reinsurer and finance department for appropriate reserve allocation
• Clarifies health plan medical benefits, policies and procedures for members, physicians, medical office staff, contract providers, and outside agencies
• Responsible for the early identification and assessment of members for potential inclusion in a comprehensive case management program. Refers members for case Management accordingly
• Provide back up for other members of the Medical Management team when needed
• Minimum 3 years clinical experience as RN or LPN required
• Minimum 5 years managed care or equivalent health plan experience preferred
• Demonstrated experience in health plan utilization management, facility concurrent review (hospital, skilled nursing facility, acute rehabilitation), discharge planning, and transfer coordination required
• Medicare Advantage experience preferred
• Experience with InterQual or Milliman authorization criteria required
• Excellent computer skills and ability to learn new systems required
• Strong attention to detail, organizational skills and interpersonal skills required
• Demonstrated ability to problem solve and manage professional relationships
• Conduct recertification, and extensions of utilization review services which may include determinations for inpatient and outpatient admissions, physical, occupational, or chiropractic therapy treatments, diagnostic testing, etc., using nationally recognized criteria and personal clinical experience and medical knowledge
• Initiate referrals to Peer Review Services appropriately, and coordinate the services to support the utilization review. Ensure that peer review decisions are communicated within 1-2 business days
• Perform Utilization Management services within established clinical, productivity, phone and URAC standards. This includes ensuring that an Utilization Management determination is communicated to the provider within two business days of receipt of the medical information or as determined by Worker's Compensation law
• 3+ Years of relevant nursing experience
• Current nursing registration required
• Basic knowledge of states workers' compensation laws, disability management and utilization product review preferred
• Strong communication and interpersonal skills in order to receive and/or exchange information with healthcare providers, vendors, customers/injured workers, regulatory agencies, and legal professionals
• Ability to work independently and be a problem solver under general instructions and with a team
• Experience working in a skilled nursing facility a plus
• Experience having to navigate multiple electronic medical record (EMR) systems a plus
• Reviews charts and analyzes clinical record documentation
• Conducts ongoing activities which monitor established quality of care standards in the participating provider network and for other clinical staff
• Collects, analyzes and prepares clinical record information for projects related to assessing the efficiency, effectiveness and quality of the delivery of managed care services. Prepares monthly performance reports
• Assists in the planning and implementation of activities to improve delivery of services and quality of care including the development and coordination of in-service education programs for providers and other clinical staff
• Provides training, interpretation and support for QI Clinical Reviewer staff
• Responsible for auditing as well as validating internal audit results and/or corrective action plans
• Two (2) years managed care experience in UM/CM Department, preferred
• Knowledge of CMS, State Regulations, URAC and NCQA guidelines preferred
• ICD-9 and CPT coding experience a plus
• Experienced computer skills with Microsoft Word, Microsoft Outlook, Excel and experience working in a health plan medical management documentation system a plus
• Minimum Education: LVN
• 2 Years Health Plan Utilization Review or equivalent
• Preferred Experience: 5 years Health Plan Utilization Review
• 5 years Acute Care experience with 1 year ICU / ER
• Includes ability to walk through hospital-based departments across broad campus settings, including Emergency Department environments
• Office Work Environment

Utilization Management Nurse Associate Resume Examples & Samples

• Licensed Nurse, LPN or RN (RN is preferred)
• 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years (Required)
• Managed Care experience (preferred)
• Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel Excellent verbal/written communication skills
• Able to work independently in a virtual environment - and adjust to change

Senior Utilization Management Nurse RN Resume Examples & Samples

• Ability to work in a Matrix environment with little to no direction
• Identify solutions to non-standard requests and problems
• Experience developing; implementing and executing Utilization Management programs, work plans and program descriptions
• Prepare documentation and oversee all Utilization Management committees
• Delaware RN license
• 3 or more years of Managed Care and / or Clinical experience
• Ability to create, edit, save and send documents utilizing Microsoft Word. Ability to navigate a Windows environment and other computer based programs
• Prior-authorization experience
• Utilization Management experience
• Acute care or Managed care Case management and / or Utilization management experience
• Knowledge of Milliman Criteria and Interqual Criteria

Utilization Management Nurse Consultant Resume Examples & Samples

• Licensed Registered Nurse required
• 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas
• Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel
• Excellent verbal/written communication skills
• Able to work independently in a virtual environment and adjust to change
• Develops and manages new enrollee transitions and those involving a change in provider relationships. Develops and implements transition plans, as indicated, to ensure continuity of care. Negotiates and documents single case agreements according to the company's procedures
• Reviews planned, in process, or completed health care services to ensure medical necessity and effectiveness according to evidence-based criteria. Proposes alternatives when the requested services do not meet medical necessity criteria or are outside the contracted network. As assigned and based on credentials, monitors and reviews specialized requests and treatment records such as Treatment Record Forms
• In conjunction with providers and facilities, identifies, develops and monitors discharge plans. Collaborates with the Care Coordination Team to implement support for transitions in care. Facilitates timely sharing of enrollees? clinical information (such as previous treatment, medications, and planned care) in order to promote continuity of care
• Provides information to enrollees, providers, and internal staff regarding covered and non-covered benefits, community resources, agency programs, and company policies and procedures and criteria
• Interacts with Medical Directors and Physician Advisors to provide case information and discuss clinical and authorization questions and concerns regarding specific cases. Assures that case documentation for each decision is complete, including related correspondence
• Participates in Care Coordination Team and utilization management activities, including collaboration with other staff on enrollee cases, and performing data collection, tracking, and analysis
• Maintains an active work load in accordance with performance standards
• Works with community agencies as appropriate
• Participates in network development including identification and recruitment of quality providers as needed
• Advocates for the enrollee to ensure health care needs are met. Interacts with providers in a professional, respectful manner
• Provides coverage of Nurse Line and/or Crisis Line as requested or required for position
• 3 years experience post degree in a clinical, psychiatric and/or substance abuse health care setting. Also requires minimum of 3 years of experience conducting utilization management according to medical necessity criteria
• An active and good standing LPN license for Illinois is required
• 1-2 plus years of clinical experience is required
• 2 years of managed care experience is preferred
• Nursing Baccalaureate degree (BSN) from an accredited school of nursing
• Current Washington State Nursing license
• Three or more years of RN experience in a clinical setting
• ACM or CCM certification
• One or more years of case management experience
• An active and good standing LPN license is required for the state of Utah
• 3-5 years clinical experience in a hospital setting is required
• 1-3 years of Managed Care experience is preferred
• Excellent computer skills and ability to multi task and navigate multiple computer systems including Outlook, Word and Excel are required
• Excellent verbal/written communication skills are required
• Experience with Medicare is preferred
• Minimum of 3-5 years of clinical experience required (preferably in an acute hospital inpatient setting)
• Minimum of 1-3 years of Medical/Surgical (Med/Surge) experience required
• Active and unrestricted Registered Nurse (RN) License required
• 1-3 years of concurrent review/discharge planning experience preferred
• 1-3 years of Home Health Care Ambulatory Nursing experience preferred
• An active and good standing RN license is required
• Excellent computer and typing skills are required
• Excellent time management Skills are required
• 2 years of clinical experience required
• Utilization Management experience preferred
• 2+ years of Utilization Review / Case Management experience; 1+ year of Clinical experience in the Healthcare field
• FL Registered Nurse (RN) license and/or Licensed Practical Nurse (LPN)
• Knowledge of InterQual Criteria, Florida Medicaid Program, and CMS Guidelines
• Previous experience in an Inpatient and/or Outpatient setting
• 1+ year of experience in Discharge Planning in an Acute Care setting
• Determine medical appropriateness inpatient and outpatient services following evaluation of medial guidelines and benefit determination
• Assess and interpret customer needs and requirements
• Provide explanations and information to others on Difficult issues
• Coach, provider feedback and guide others supplying health education as needed
• Participate in Clinical Services Coordinator mentoring and on-going education
• Unrestricted RN license required in state of residence
• 4 or more years of Managed care and / or Clinical experience
• Experience with the Elderly and / or Intellectually Disable (ID) or Developmentally Disable (DD) population
• 2+ years of experience with documenting processes and practices while effectively prioritizing multiple tasks, priorities, projects and deadlines
• Proven ability to build collaborative relationships, work with colleagues and external audiences and partner in areas of system change, housing development / operations and / or the delivery of supportive services
• Ability to take initiative to implement projects and pursue goals with moderate supervision
• Intermediate level of proficiency with PC based software programs and automated database management systems required (Excel, Access, PowerPoint)
• Experience and knowledge with Medicaid / TennCare and Long-Term Services and Supports providers
• Ability to navigate a Windows environment including Microsoft office
• Excellent written and verbal communication and presentation skills
• Ability to balance multiple high priority
• 3-5 years of Clinical experience (Required)
• Active Unrestricted RN license (Required)
• Managed Care experience (Preferred)

Utilization Management Nurse Reviewer Resume Examples & Samples

• Evaluates clinical information using established national decision support criteria, Medical Mutual policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Advisor. Manages initial, concurrent and retrospective review of cases, including appeals. Initiates and maintains positive relationships with internal and external customers. Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner. Identifies and refers members with potential health care needs to case and health management services. Coordinates with other care management departments to ensure the timely provision of covered health care services
• Registered Nurse with 3 years recent nursing experience with State of Ohio license
• 3 years current medical/surgical experience
• Knowledge with medical terminology/coding and managed care processes
• Personal Computer skills using Windows-based programs and applications, including Basic MS Office Skills
• Evaluates clinical information using established national decision support criteria, Company policies, individual patient considerations, and clinical judgment to determine appropriateness of services and procedures. Refers cases that are complex or outside the established criteria and guidelines to the Physician Reviewer
• Manages initial, concurrent , and retrospective review of cases, including appeals
• Initiates and maintains positive relationships with internal and external customers
• Meets department standards for accuracy, quality and documentation in order to communicate decisions in an appropriate and timely manner
• Identifies and refers members with potential health care needs to case and health management services. Coordinates with other care management departments to ensure the timely provision of covered health care services
• Registered Nurse with 3 years recent nursing experience
• 3 years current medical/surgical nursing experience
• Licensed State of Ohio Registered Nurse
• Knowledge with medical terminology/coding and managed care processes. Personal Computer skills using Windows-based programs and applications, including Basic MS Office Skills
• No prior UM experience necessary. We will train. Hospital experience helpful, but new grads will be considered
• Ability to apply UM criteria, and conduct telephone inpatient review of hospital/SNF patients. Must be able to review medical records at times
• Ability to coordinate discharge plans
• Excellent clinical knowledge required
• Ability to be nimble and learn to think out of the box important

Lpn-utilization Management Nurse Associate Resume Examples & Samples

• 3-5 years clinical experience in a hospital setting is required; 1-3 years of managed care experience
• Excellent computer skills and ability to multi task and navigate multiple computer systems including Outlook, Word and
• Excel are required
• Conduct telephonic reviews for inpatient facilities for both concurrent and retrospective reviews for appropriateness of treatment setting reviews to ensure compliance with applicable criteria
• Process Prior Authorization requests for medical necessity of Outpatient services including Rehab, Home Health and DME
• Apply clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilize evidence-based criteria that incorporates current and validated clinical research findings. Practice within the scope of their license
• Provide care coordination for members who are transitioning from one level of care to another
• Collaborate with providers to assess members, needs for early identification of and proactive planning for discharge, transfer and redirection
• Identify barriers to efficient utilization and facilitate resolution
• Collaborate with other departments to resolve claims, quality of care, member or provider issues
• Identify problems or needed changes, recommends resolution, and participates in quality improvement efforts
• Maintain and enhance relationships between the business and the provider community
• Provide consistent and accurate documentation
• Consult with physician advisors to ensure clinically appropriate determinations
• Work within a team to move the member through the continuum of medical management with the goals of facilitating quality health care through the most cost effective means
• 2 – 5 years’ related experience; or an advanced degree without experience; or equivalent directly related work experience
• 1-3 years’ experience in Concurrent Review, preferred
• Previous experience in Medicare Advantage managed care and Medicaid programs is a plus
• Experience with ESRD and/or dialysis is a plus
• Familiarity with CPT and ICD codes a plus
• Familiarity with Medicare Guidelines and MCG a plus
• Effective time management
• Collaboration and negotiation skills
• Excellent analytical skills
• Must be organized and detail oriented with a strong bias for follow-up and problem resolution
• Screening of PAL procedures. Conference calling will be performed from the Central Office
• Maintenance of documentation on concurrent review through the automated AMISYS Medical Management System
• Retrospective chart review of questionable hospitalizations in outlying hospitals when indicated. Chart audit of inpatient charges
• Work closely with physician advisors and Medical Directors Council to update and maintain policy according to industry standard
• Maintain direct review responsibilities for a designated geographic area of review
• Any additional duties as assigned
• Provide prior authorization utilization management to best meet the member’s specific healthcare needs and to promote quality and cost-effective outcomes and appropriate payment for services
• Knowledge of health insurance industry trends, technology and contractual arrangements
• General computer skills (including use of Microsoft Office, Outlook, internet search). Familiarity with health care documentation systems
• Strong verbal, written and interpersonal communication and customer service skills
• Ability to interpret policies and procedures and communicate complex topics effectively
• Strong organizational and time management skills with the ability to manage workload independently
• Ability to think critically and make decisions within individual role and responsibility
• Must have current unrestricted Registered Nurse (RN) license, in a state or territory of the United States, that allows the professional to conduct an assessment independently as permitted within the scope of practice for the discipline and at least 3 years (or full time equivalent) of direct clinical care
• Applies clinical expertise and judgment to ensure compliance with medical policy, medical necessity guidelines, and accepted standards of care. Utilizes evidence-based criteria that incorporates current and validated clinical research findings. Practices within the scope of their license
• Consults with physician advisors to ensure clinically appropriate determinations
• May facilitate transitions of care through collaboration with the member, the facilities interdisciplinary team and Regence’s Case Management to achieve optimal recovery for the member
• Serves as a resource to internal and external customers
• Collaborates with other departments to resolve claims, quality of care, member or provider issues
• Identifies problems or needed changes, recommends resolution, and participates in quality improvement efforts
• Responds in writing, by phone, or in person to members, providers and regulatory organizations in a professional manner while protecting confidentiality of sensitive documents and issues
• Provides consistent and accurate documentation
• Plans, organizes and prioritizes assignments to comply with performance standards, corporate goals, and established timelines

Utilization Management Nurse Clinician Resume Examples & Samples

• Managed Care experience preferred. 3-5 years of clinical experience; Required
• Registered Nurse with Behavioral Health experience; Required
• Position requires proficiency with computer skills which includes navigating multiple systems and keyboarding; Required
• Effective communication skills, both verbal and written; Required
• Ability to multitask, prioritize and effectively adapt to a fast paced changing environment; Required
• Communication and collaboration with Medical Director
• Case preparation and presentation for Medical Director review
• Documentation in HER of supportive rationale for UM decision
• Timely and accurate documentation in database of UM decision
• Ability to create, edit, save and send documents utilizing Microsoft Word
• State Medicaid Managed Care Experience
• Pre-authorization experience

Utilization Management Nurse Case Management Resume Examples & Samples

• Medical record investigative review knowledge
• Computer knowledge including basic computer skills; Windows and Outlook
• Knowledge of specific Florida Hospital computer-based programs as well as Microsoft word, Excel and Outlook (Preferred)
• Nursing education
• Acute clinical experience of at least five (5) years
• Acute clinical case management, discharge planning and/or utilization management experience in a healthcare clinical setting, i.e. hospital, managed care, home health, and/or Center for Medicare and Medicaid Services Programs, etc. (Preferred)
• BSN (Preferred)
• Certification specialty preferred in Utilization Management, Managed Care or other applicable professional certification (Preferred)
• Proficient in navigating between multiple systems with dual monitors; Required
• Accurately touch type on a keyboard at efficient speed; Required
• The ability to exercise independent and sound judgment, has strong decision-making skills and well-developed interpersonal skills; Required
• Ability to manage multiple priorities, effective organizational and time management skills along with strong teamwork skills; Required
• Managed Care experience and prior experience within a telephonic customer service center type of environment; Preferred
• Candidate must possess strong computer skills
• ATV and ASD for internals candidates; Required
• An RN license is required
• Strong communication and technology skills are required
• Discharge planning experience is preferred
• 3-5 years clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years; Required
• Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel Excellent verbal/written communication skills; Required
• Able to work independently in a virtual environment - and adjust to change; Required
• Precertification or prior authorization experience ; Strong Preference
• Determines medical necessity, appropriateness of admission, continuing stay and level of care using a combination of clinical information, clinical criteria, and third party information. Intervenes when determinations are not in alignment with clinical information, clinical criteria or third party information to resolve the situation. Documents all case management interventions in the current electronic system
• Monitors and updates accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care
• Validates admission and continuing stay criteria with third party payers as well as the Attending Physicians. Recommends alternative care sites where appropriate
• Updates discharge list for last covered day. Calls discharge date to payer or submit discharge review
• All new admission reviews are to be completed within 1 business day
• Confirmation of pre-certification or authorization for admission
• Interqual Criteria is to be utilized with each new admission as well as with every denial
• Inform the case manager of any issues or plans noted in the documentation
• Self-Pay cases should be referred to Family Health Coverage Program (FHCP) and/or Social Work to determine if coverage is pending or if application for coverage has been made
• Adheres to established departmental policies, procedures, and objectives
• Enhances professional growth and development by accessing educational programs, job related literature, in-service meetings, and workshops/seminars
• Maintains established department/hospital/system policies and procedures, directives, safety, environmental and infection control standards appropriate to this position
• Demonstrates a courteous and professional manner through interactions with internal and external customers
• Integrates scientific principles and research based knowledge in decision making
• Exemplifies a professional image in appearance, manner and presentation
• Engages in self-performance appraisal, identifying areas of strength as well as areas for professional development
• Researches, selects and promotes adaptation of best practice findings to ensure quality patient care and optimal outcomes
• Adapts behavior as needed to the specific patient population, including but not limited to: respect for privacy, method of introduction to the patient, adapting explanation of services or procedures to be performed, requesting permissions and communication style
• Performs other related duties as assigned

Utilization Management Nurse Review Specialist Resume Examples & Samples

• Assist in the control of utilization of resources, pre-occurrence monitoring, concurrent monitoring, intervention and retrospective review
• Track, trend and evaluate appropriateness and quality of care issues with the implementation of education to internal and external customers and process improvement initiatives
• Responsible for the implementation of a comprehensive outpatient/inpatient review process utilizing criteria based review standards and standards of best practice
• Facilitate quality health care intervention recommendations
• Review and assess over/under utilization issues
• Identify and document comparisons with community standards, regionally based as indicated
• Work with other UM inpatient and outpatient nurse reviewers to assure proper treatment in the appropriate setting at the appropriate time
• Participate in CEU offerings/seminars to enhance professional growth and development and the maintenance of nursing license
• Assist in completion of special projects on an as needed basis
• RN with current unrestricted New York state licensure; Required
• Proficiency with computer skills which includes navigating multiple systems and keyboarding
• Effective communication skills, both verbal and written. Ability to multitask and prioritize
• Ability to work nights and weekends per business needs
• Managed care experience preferred
• Benefits management experience preferred
• CCM (Certified Case Manager) preferred

Rn-utilization Management Nurse Consultant Resume Examples & Samples

• Managed Care experience preferred
• Inpatient (Hospital) experience is required
• ICU, ER or Med/Surg are highly preferred!
• Strong computer and typing skills are needed!
• Must know Word and Outlook!

Utilization Management Nurse Rn-ridgeland Resume Examples & Samples

• Will work Onsite at: 795 Woodlands Parkway, Suite 301 Ridgeland MS 39157
• Perform utilization management, utilization review, or concurrent review (on-site or telephonic Care coordination)
• Monitor, Track, and trend and report Utilization Inpatient and Outpatient Service Patterns
• Act as a resource for others with less experience
• The position is required to be onsite and works closely with the Health Services Director to ensure contractual compliance (Contributes RFPs and proposals and review if internal policies and procedures)
• Will be responsible for program evaluation for Utilization Management Program evaluation and Coordinating reports for Quality Committees
• Responsible for assisting providers with UM processes
• Reviewing and responding to appeals and general inquiries and state inquiries
• 3 or more years of Managed Care and / or Clinical experience required
• Undergraduate degree

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