1637 Lady Bug Drive
Colorado Springs, CO 80903
Career Objective To obtain a position as an Utilization Review Nurse where my special skills can be used to their fullest potential to help improve the hospital.
Summary of Qualifications:
- Remarkable experience in geriatric nursing, renal, cardiac and endocrinology
- Exceptional knowledge of utilization review, case management, and disease management
- Solid understanding of state and federal regulatory requirements affecting care coordination services, specifically CMS, Medicaid and HIPAA
- Proficient in Microsoft Word, Excel and utilization review modules in information systems
- Ability to work as a team member to strategize future program enhancements
- Ability to provide commitment to excellence in nursing and to communicate well with frail elderly and providers
Utilization Review Nurse, August 2005 – Present
Coventry Health Care, Colorado Springs, CO
- Managed assigned workload within established performance standards.
- Participated in discharge planning process with hospital and inpatient facility staff, ensuring adequate and appropriate disposition and post discharge plans.
- Coordinated smooth transition and follow-ups from one level of care and service to another.
- Maintained all required documentation in the information systems.
- Participated in case conferences, clinical in-services, and other educational opportunities.
- Recorded information in Claims Management system and communicated with the Claims Adjuster to process valid medical treatment requests for authorization per policy.
Utilization Review Nurse, May 2000 – July 2005
XLHealth, Colorado Springs, CO
- Determined medical necessity of the requested treatment.
- Communicated with requesting providers, service providers, claims adjusters and claimants via telephone and fax to request additional information.
- Coordinated care and provided verbal authorization for medical treatment per policy.
- Assisted in medical training for claims adjusters.
- Maintained ongoing compliance with federal, state or Federal laws, URAC standards.
- Ensured cost effective and quality patient care by appropriate utilization of medical resources.
B.S in Health Services Management, Florida State University, Tallahassee, FL
602 S Main St
Oak Park, CA 91301
Objective Looking for a challenging role as an Utilization Review Nurse in the field of the nursing and caring where my skills and knowledge can be utilized effectively.
- Immense ability to work under stress, both with and without supervision.
- Strong ability to quickly analyze and interpret data.
- Extensive working experience in the field of case management and utilization review.
- Sound knowledge in conducting and reviewing medical record for medical necessity.
- Wide knowledge of health care service delivery schemes and third party reimbursement.
Utilization Review Nurse, 2004 to till date
UCLA Medical Center, Los Angeles, CA
- Maintained records of the utilization review department.
- Monitored and reported on patient activities, mental status and progress to the insurance company.
- Performed utilization review in accordance with all state mandated regulations.
- Reviewed patient’s records and evaluated patient’s progress.
- Aided and coordinated telephonic and on-site inpatient and outpatient care through precertification, concurrent review and discharge planning.
Health Care Quality & Management Board Certification, 2004
Yale School of Nursing, New Haven, CT
B.S in Nursing, 2003
University of Washington, Seattle, WA