Utilization Review Nurse Resume

Sabrina Thomas

1637 Lady Bug Drive

Colorado Springs, CO 80903

(555)-555-5555

[email]

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

Work Experience:

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.

Education

B.S in Health Services Management, Florida State University, Tallahassee, FL

Example #2

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.

Career Profile:

• 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.

Nursing Experience:

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.

Academic Background

Health Care Quality & Management Board Certification, 2004

Yale School of Nursing, New Haven, CT

B.S in Nursing, 2003

University of Washington, Seattle, WA