Entering information via computer system approving medical criteria to insure payment of claims in a timely manner. Possess special sensitivity to meeting diverse needs in varied situations. Writing a great registered nurse cover letter is an important step in getting hired at a new job, but it can be hard to know what to include and how to format a cover letter. Skills : Strong Clinical Reasoning, Medical Records Review, Excellent Organizational Skills, Excellent Interpersonal Communication Skills. Responsible for obtaining and reviewing daily clinical information for concurrent review, extending the length of stay as medically necessary. Strong analytical skills, capable of assessing conditions and implementing appropriate intervention. Skills : Utilization Review, Case Management, Excellent Organizational Skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel. Reliable, an ethical healthcare provider with the ability to stay calm and intervene during crises, and to collaborate on multidisciplinary teams. This positions focus will involve and support Manage Long Term Care program, homecare and personal care program activities to include pre-authorizations of and concurrent review of medically necessary services. 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. Although the UR concept isn’t new, the nature of the role and demands on utilization reviewers have […] Participated in WebEx meetings for information distribution and educational needs. Follow these steps to create your customized entry-level, registered nurse cover letter… Provides utilization management services and support to health insurance members and health care providers, including but not limited inpatient admissions, continued stay reviews, service referrals and out-of-network referrals. Performed utilization review activities for Medipass population. 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. Made recommendations for approval for utilization review requests for treatment given the request fell within evidence-based medical literature set for in the algorithm. Communicates with team to review issues/concerns to ensure that there is appropriate work flow, communication and documentation on each file. 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. Home based position using company supplied equipment including laptop and printer. Communicated with the medical director as needed to expedite the decision making process. Conducted stay reviews for all active duty personnel hospitalized in the community and facilitated transfer to military hospitals when indicated. Apply excellent ability to determine the medical necessity and appropriateness of care using established criteria. Monitored and reported on patient activities, mental status and progress to the insurance company. How much does a Utilization Review Nurse make? Conducts pre-certification, inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria. Conducted prior-approval first level review for all requested out-patient testing and specialty review consults for active duty personnel. Identify the primary care nurse in the hospital and monitored critical pathways, as applicable. Utilizes nursing experience and judgment in addition to the client-specific guidelines when determining medical necessity and quality check dates. To ensure the effective and efficient use of health care services. Certified in MCG (Milliman Care Guidelines) criteria to evaluate medical need. Served as the liaison between patients, doctors, healthcare providers, and insurance companies. Utilization Review Nurse 09/2011 to 09/2014 Quantum Health – Columbus, OH. Do you need the best Utilization Review resume? Maintained confidentially and compliance adhering to Health Insurance Portability and Accountability Act (HIPPA) guidelines when reviewing medical documentation. Maintain knowledge of policy and procedure manual for medical/behavioral health services requiring certification including. Coordinate coverage for rental or purchase of durable medical equipment and records details of these interactions and approve claims for payment. Proficiently established positive and effective work relationships with co-workers, adjustors, providers, and nonmedical staff. Utilization Review Nurses are primarily concerned with the efficient operation of healthcare. Some offer individual classes on the subject that licensed RN's can take through extension and continuing education offerings. Participated in the development of policies, standards, and guidelines to oversee the performance of agencies contracted to provide mental health treatment statewide. Headline : Proven record of reliability and responsibility. Develops expertise in a managed care plan Utilization Management process. Reviewed medical records for ICD 9, CPT and DRG. A successful cover letter should highlight examples of your bedside manner and empathy as well as your emotional stability and composure in difficult situations. Having management experience in sub-prime lending, consistently recognized as a top performer. The best examples from thousands of real-world resumes, Handpicked by resume experts based on rigorous standards, Tailored for various backgrounds and experience levels, Determined appropriateness and medical necessity of hospitalization and requested treatment (s) based on plan's guidelines, policies, Milliman, and medical director review, if needed. Participated in multi-disciplinary patient case management at the clinic level. Met and exceed accuracy and quality standards efficiently multitasking and triaging caseload. Plan discharge from care facility to home or another care facility. Assists hospital staff in identifying post-acute care needs in accordance with product insurance benefit availability. Review patient specific information to ensure medical necessity for requested durable medical equipment, home health services and supplies using InterQual criteria and/or state regulated guidelines, Demonstrate critical thinking, interpersonal oral and written communication skills to support review findings, Ensure consistent application of the utilization review process for all functioning components, Verify eligibility and review past utilization history, Participate in special projects and monthly meetings, Followed compliance rules and regulations for accurate billing of durable medical equipment, home health services and supplies. Provide case summaries to insurance companies, Communicate with insurance companies and informing them of clients current progress and future treatment plan with the goal of obtaining further authorization, Complete follow through for disposition of cases- MD reviews, chart reviews, audits, case management referrals, Determine patient review dates according to established diagnostic criteria, Assist review committee in planning and holding federally mandated quality assurance reviews. Acted as team lead for remote home based employees providing support and answer questions as appropriate. Reviewed claims for the severity of illness and necessity of service; request supplemental information as needed to finalize claim determination. , Communication skills, Computer Proficiency-Microsoft Word, Microsoft PowerPoint, Microsoft Excel and therapeutic environment for patients direct. 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