Review Nurse Resume Sample

23 votes

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Pauline Von
2398 Uriel Locks,  Phoenix, AZ
+1 (555) 333 3457

Work Experience

Retrospective Review Nurse
04/2018 - PRESENT
Houston, TX
  • Understands and self-manages to support facility/CIN-level success goals, including improvements in quality, cost of care and member experience for the facility/CIN’s population
  • Evaluates medical claims and/or medical records by applying clinical expertise to assess appropriateness of service provided, length of stay and level of care. Identifies and refers all cases not meeting medical necessity criteria and guidelines to appropriate decision maker for review
  • Evaluates and intervenes as needed for level of care, denial and compliance issues
  • Identifies and refers members with special needs to the appropriate Wellcare Healthcare program per policy/protocol
  • Documents clinical review summaries, bill audit findings and audit details in the system
  • Maintain current knowledge of the TRICARE program
  • Acts as patient/family advocate in coordinating and accessing medical necessity health care services within the benefit plan (Associate Level)
  • Performs Condition Management services which includes educating members on self-management of a chronic condition in order to facilitate the best health possible (Associate Level)
  • Refers patients to appropriate resources to allow for positive outcomes relating to their chronic illness
Clinical Claims Review Nurse
11/2015 - 11/2017
Philadelphia, PA
  • Facilitates electronically filing of medical records in the appropriate format and location
  • Responds to phone calls from providers regarding existing cases
  • Educate and assist patients in understanding and self-manage their chronic conditions within current medical practice
  • Participates in quality improvement strategies by assessing individual and employer satisfaction of programs
  • Identifies and addresses quality issues
  • Identifies potential cost savings within a health plan's coverage
  • Acts upon cost savings in instances when services would not be sacrificed by doing so
  • Obtains/maintains knowledge of Federal, State and Local funding and community resources available to patients and their families
  • Perform within professional practice guidelines set forth by state Board of Nursing and Division of Worker’s Compensation
Second Level Review Nurse
05/2013 - 06/2015
Dallas, TX
  • Demonstrates the ability to work in a team environment and effectively participates in cross-functional teams
  • Conducts outreach to requesting providers which can include specialty physicians, ancillary providers and institutions to gather the appropriate/necessary clinical data
  • Refers cases to other professionals internally, including case management and medical consultation when indicated
  • Ensures the integrity and high quality of utilization management services
  • Strictly follows company policies related to the handling, release and disposal of confidential information
  • Ensures that the Operations Manager or designee is made aware of any potential risk management issues in a timely manner
  • Consistently meets medical management standards for attendance and punctuality


Franciscan University of Steubenville
2008 - 2013
Bachelor's Degree in Nursing

Professional Skills

  • Strong analytic and critical thinking skills required
  • Strong documentation, follow up and organizational skills required
  • Effective communicator; motivational interviewing or related skills desired
  • Prior on-call triage experience
  • Prior Assessment experience
  • Skilled Nurse Facility or Home Health experience
  • Maintains benefits knowledge, clinical knowledge and skills, which encompass internal business operations

How to write Review Nurse Resume

Review Nurse role is responsible for clinical, insurance, reporting, benefits, auditing, training, finance, health, excel, outlook.
To write great resume for review nurse job, your resume must include:

  • Your contact information
  • Work experience
  • Education
  • Skill listing

Contact Information For Review Nurse Resume

The section contact information is important in your 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
  • Email
  • Telephone number

Work Experience in Your Review Nurse Resume

The section work experience is an essential part of your 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 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 review nurse position you're applying to. The work experience section should be the detailed summary of your latest 3 or 4 positions. Representative Review Nurse resume experience can include:

  • Organization/time management and prioritization skills
  • Licensed RN or LPN with a strong understanding of electronic medical records system (EMR)
  • Experience establishing a partnership approach with customers/clients/co-workers to accomplish goals and exceed performance expectations
  • Chart Auditing Experience helpful
  • Initiates new or improved workflow processes to increase efficiency and effectiveness of the Utilization Review and Clinical Consultation departments
  • Data Analysis Interview experience

Education on a Review Nurse Resume

Make sure to make education a priority on your 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 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 Review Nurse Resume

When listing skills on your 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 review nurse skills:

  • Effectively and efficiently collect and analyze data
  • Performing concurrent reviews with weekly onsite travels to surrounding area skilled nursing facilities
  • Nursing experience (at least 2 of the following: M/S, Critical Care, ER, surgical)
  • Acute care clinical nursing experience
  • Utilization Management experience in managed care, acute or rehab setting
  • Knowledge of medical terminology and/or experience with CPT and ICD-10 coding

List of Typical Skills For a Review Nurse Resume


Skills For Retrospective Review Nurse Resume

  • Experience in utilization management with a health plan or hospital based UM dept. with use of Interqual or MCG
  • UR/UM, previous air ambulance review flight nurse experience
  • Workers Compensation experience required
  • Clinical practice experience required
  • Clinical quality review/audit experience required; e.g. Audit tool development
  • Recent experience in Utilization Management
  • Working knowledge of care management, NCQA, best practice e.g. care plans/SMART goals

Skills For Medically Managed Bill Review Nurse Resume

  • Working knowledge of Microsoft Office suite required, specifically Word, Excel and Outlook
  • Current RN license in practicing state. If supporting PCS license is not required
  • Knowledge of performance improvement, teaching/learning principles and peer review
  • Determine medical necessity and appropriateness of services using clinical review criteria
  • Accurately document all review determinations and contact providers and members according to established timeframes
  • Perform Post-acute reviews for patients discharging from Self Regional
  • Writes authorization requests utilizing all available patient information
  • Obtains approved authorization numbers via on-line access or telephone, depending upon the states’ agencies
  • New York State Nurse Certification

Skills For Clinical Claims Review Nurse Resume

  • Perform utilization review of home health services and SNF admissions
  • Appropriately identify and refer quality issues to Medical Management or Medical Director
  • Implement and monitor clinical network savings initiatives for the market
  • Ensure that the implementation plan and development of the initiatives is sufficient to address the objectives
  • Thorough knowledge of multi-disciplinary, organizational and Clinical aspects of patient care delivery
  • Works closely with review organizations, business office, medical staff services, nursing services and the medical staff in a friendly, courteous and efficient manner in order to educate all parties regarding Performance Improvement

Skills For Quality Review Nurse Resume

  • Educate providers on utilization and medical management processes
  • Participate in utilization management committees and work on special projects related to utilization management as needed
  • Audit case reviews to ensure compliance with utilization management policies and procedures
  • Assist with the development of utilization management workflows, policies, and procedures
  • RN Licensure in state of Pennsylvania is required

Skills For Second Level Review Nurse Resume

  • Residence and active RN license in the state of Arizona
  • Licensure/Certification: Current SC RN License
  • A current, unrestricted RN license for the state of Nevada
  • Proficient with Microsoft Word to create, edit, save and send documents. Ability to navigate a Windows environment, Microsoft Outlook, and conduct Internet searches
  • Knowledge of ICD9 / CPT coding and Milliman Care Guidelines
  • LPN licensed in applicable state
  • Knowledge of Milliman or InterQual guidelines

Skills For Preservice Review Nurse Resume

  • Intermediate Other Knowledge of Milliman or InterQual guidelines
  • Work location is Onsite at the facility
  • Active RN license in GA
  • Perform Acute Inpatient reviews at Self Regional
  • Familiarity with MCG or Interqual
  • At all times treats others with dignity and respect

Skills For Rn-review Nurse Resume

  • Review medical records (electronic and hardcopy) to determine if retrospective authorization is required
  • Documents all diagnostic procedures with CPT and ICD9/ICD-10 codes accurately and efficiently
  • Submits first level appeals in a timely and efficient manner and notifies appropriate parties of expiration dates
  • Performs documentation in company system and hospital’s system if required
  • Responsible for performing pre-service clinical coverage review of services (predetermination reviews), using applicable benefit plan documents, evidence - based medical policy and nationally recognized clinical guidelines and criteria

Skills For Utiltization Review Nurse Resume

  • Identify member’s Third Party Liability coverage
  • Review claims with clinical reviewer when criteria is not met
  • Review clinical information and claims with Medical Director when clinical determination is necessary
  • Update authorizations as directed by the Medical Director
  • Maintains accurate record system of results clinical assessment nurse review to include results of assessment and rationale. Ensures the accuracy of the information before filing
  • Maintain productivity standards and maintain compliance with all regulatory agencies including NCQA, DOL, DOI for each state, Medicaid, CMS and OPM

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