Utilization Management Nurse Resume Sample

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Faye MacGyver
2634 Lehner Falls,  Philadelphia, PA
+1 (555) 593 2077

Work Experience


Utilization Management Nurse Associate
08/2016 - PRESENT
San Francisco, CA
  • Proficient in navigating between multiple systems with dual monitors
  • Accurately touch type on a keyboard at efficient speed
  • Clinical experience required (NICU, Pediatric)
  • Conducts concurrent reviews and coordinates discharge planning activities with the Primary Care Physician office
  • Identifies candidates for the DaVita Medical Group's Disease Management and Complex Care Management Programs
  • Functional - Nursing/Concurrent Review/discharge planning/1+ Years
  • Technical - Operating Systems/Windows/1+ Years/End User
  • Applies utilization review criteria to medical record information to evaluate the appropriateness of care setting. Recommends alternatives to inpatient management. Enters review outcome into UM screens
Utilization Management Nurse
12/2011 - 07/2016
New York, NY
  • Confers with physicians and Physician Advisors when medical record documentation fails to meet criteria
  • Collaborates with Care Coordinator to assess patient's clinical course and verify need for acute hospital level of care or medical stability for care at the next level. Utilize the Care Coordinator as a resource for additional information and day to day problem resolution
  • Collaborates with Care Coordinator to identify factors contributing to delays in service or delayed discharge. Reports findings to Director of Care Management
  • Participates in daily patient care rounds. Shares results of utilization management record review findings. Explains SI/IS/DS (InerQual) criteria and discuss documentation that qualifies the patient for acute hospital level of care, reimbursement and readiness for discharge to the next level
  • Exchanges information with insurance on-site review nurse
  • Completes Medical Assistance 3808's as assigned
  • Participates in nursing unit and department clinical outcomes activities
  • Demonstrates commitment to work partners to help each other reach mutual goals and learn from each other. Demonstrates actions and behaviors that consistently promote trust, respect, a positive attitude and promote team morale
  • Graduate of an approved Registered Nursing program
Utilization Management Nurse Rn-telecommute
09/2009 - 10/2011
New York, NY
  • Five years of clinical nursing in an acute care hospital setting
  • Two years of Utilization Management experience
  • Uses critical thinking to determine if treatments are consistent with member's diagnosis and clinical needs. Ensures services provided are within benefit plan and that appropriate contracted providers are utilized
  • Identifies needed information. Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits
  • Initiates interactions with providers regarding anticipated progression of care and transitions across treatment settings. Facilitates referrals for follow up providers and support services
  • Evaluates clinical information to identify and present cases during rounds. This includes identification of members at high risk for complicated medical treatment plans, readmissions potential, and admissions for potentially avoidable conditions
  • Prepares cases for review by medical director when condition or treatment plan varies from established guidelines
  • Documents clinical updates, authorizations, and referrals in the health plan care management system adhering to health plan documentation standards
  • Provides members and/or treating providers with resources to enhance their ability to access services

Education


University of Phoenix - Pleasant Grove Learning Center
2004 - 2009
Bachelor's Degree in Nursing

Professional Skills


  • Healthcare experience, including at least 2 years of Clinical practice in an Acute Care setting; 2+ years of Utilization Review experience at a Managed Care plan or Provider Organization
  • Strong computer skills including toggling with Windows, Microsoft Office and Outlook and strong keyboarding skills
  • Excellent customer service orientation and strong interpersonal skills.  Computer skills and a working knowledge of Word, Excel and Access
  • Excellent communication skills and demonstrated organizational skills
  • Exercise independent and sound judgment, strong decision-making skills and well-developed interpersonal skills
  • Excellent customer service orientation and strong interpersonal skills
  • Prior experience working in a skilled nursing facility

How to write Utilization Management Nurse Resume

Utilization Management Nurse role is responsible for computer, clinical, customer, healthcare, interpersonal, options, collaborative, microsoft, administration, documentation.
To write great resume for utilization management nurse job, your resume must include:

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

Contact Information For Utilization Management Nurse Resume

The section contact information is important in your utilization management 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 Utilization Management Nurse Resume

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

  • Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Excellent computer skills able to multi task and navigate multiple computer systems including Outlook, Word and Excel are required
  • Utilizes Utilization Management skills, including a thorough, working knowledge of InterQual criteria/Milliman Care Guidelines, by the following
  • RN experience, including recent clinical experience in an inpatient/acute setting
  • Prior experience working with MCG (Milliman)
  • Prior experience working within a home health agency

Education on an Utilization Management Nurse Resume

Make sure to make education a priority on your utilization management 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 management 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 Management Nurse Resume

When listing skills on your utilization management 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 management nurse skills:

  • Strong computer skills and experience working with the Microsoft Office suite of products
  • Manage multiple priorities, effective organizational and time management skills
  • Prior clinical experience preferably in a skilled nursing facility, acute care, or rehabilitation clinical setting
  • Prior clinical experience preferably in an acute care, skilled or rehabilitation clinical setting
  • Excellent computer skills (able to multi task and navigate multiple computer systems including Outlook, Word and Excel)
  • The ability to prioritize and effectively adapt to a fast paced changing environment

List of Typical Experience For an Utilization Management Nurse Resume

1

Experience For Utilization Management Nurse Consultant Resume

  • Sound problem solving skills. 
  • Communicates with providers and other parties to facilitate care/treatment, demonstrating superior customer service skills
  • Utilize and apply clinical knowledge, skills and resources to assess appropriate level of care based on clinical presentation and required resources
  • Clinical practice experience, e.g., hospital setting, alternative care setting such as home health or ambulatory care required
  • Experienced in working with physicians and other allied health professionals
  • An active and good standing LPN license is required
  • Clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years is required
  • Proficient experience working with outside agencies
  • State of Florida current and valid RN nursing license
2

Experience For Utilization Management Nurse Associate Resume

  • Experience in a related clinical setting
  • Clinical experience in a hospital setting that includes Medical/Surgical areas 1-3 years
  • Begins proactive discharge planning to facilitate safe and effective transitions to the next level of care, such as home or alternate discharge location
  • Identify and evaluate bed availability in all patient care departments to facilitate effective utilization of inpatient beds
  • Performs clinical utilization review to determine medical necessity and cost-effectiveness of requested health care services
  • Serve as a liaison with the clinical staff to facilitate quality of care that is cost-effective, identify organizational barriers and recommend improvements
  • Nursing License (RN) is required
  • Determines appropriate levels of coverage for inpatient stay by using clinical judgment and applying Milliman Care Guidelines to meet the member's needs
3

Experience For Utilization Management Nurse Rn-telecommute Resume

  • Integral to the concurrent review process, actively and proactively engages with member’s providers in proactive discharge/transition planning
  • Complete manufacture scripting in Oracle
  • Proficient with MS Office products including Word, Excel and Outlook
  • Responsible for providing timely referral determination by accurate
  • Discuss cases with treating physicians and other health care professionals to better understand plans of care
  • Notifies case management about interactions with insurance companies regarding services
  • Provides consultation and referral to case management program as appropriate and according to policy
  • Conduct clinical reviews for appropriateness of admissions and continuing stay as directed by VISN 10 Utilization Management Plan and any local modifications
  • Systematically document, analyze, and report administrative and clinical data translating into information for performance improvement
4

Experience For Utilization Management Nurse Review Specialist Resume

  • Educate staff (administrative and clinical) on the processes leading to both appropriate utilization of resources and quality of care
  • RN with current, unrestricted licensure in state in which work is being done required
  • Comply with New York State Article 49 guidelines when referring potential medical necessity denials to the medical director
  • Current RN license from Maryland Board of Nursing
  • Maintain authority for patient placement during the administrative tour of duty and follows priority and unit admission criteria in assigning patients to appropriate units
  • Attend daily bed briefing meetings twice daily in collaboration with the Clinical staff prior to the beginning of the shift and at the end of the shift
  • Maintain prompt, ongoing, effective communication with physicians, CNMs, charge nurses, and Environmental Management Service regarding admissions, transfers, and discharges
  • Participate in collecting, monitoring, and analyzing data related to bed availability and the bed control process, and maintaining data entry on the Bed Management solution system
  • Conduct admission review, post-discharge calls and discharge planning exceptional outcomes, embraces change, and constructively resolves barriers and constraints
5

Experience For Telephonic Utilization Management Nurse Resume

  • Utilizes effective communication, courtesy and professionalism in all interactions, both internally and externally. Assists and supports customer/account management processes as required
  • One (1) to Three (3) years of utilization experience
  • Experienced in chart and medical review
  • Certification in CPUR or CCM
  • 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
  • Effective communication of clinical information to payers to ensure support of medical necessity/level of care to successfully avoid or reverse denials
6

Experience For Utilization Management Nurse Reviewer Resume

  • Working knowledge of clinical care criteria and its application
  • Review of admission, level of care and continued stay information to determine appropriateness of hospital admission status for all payers
  • Communication of information to the CM (case management) team/physicians regarding patients not meeting established clinical criteria/standards/guidelines to enable and facilitate timely transfer/discharge to an alternative level of care
  • Complete written review/assessment of concurrent and retrospective denials; report avoidable delays based on medical records review
  • The attending physician is contacted to clarify the level of service and/or the severity of illness, if this information is not clearly reflected in the patient progress notes. When continued inpatient stay cannot be justified and a plan for appropriate level of care is not implemented notify the CM physician advisor for a 2nd level review
  • It is the responsibility of the UM Nurse to contact and educate the attending physician when documentation does not support the medical necessity for acute level of care or the admission was not pre-certified as required by the health plan
  • Establishes and maintains rapport with Business Office and collaborates to facilitate timely and appropriate reimbursement for services provided
  • Computer proficient with Microsoft Office products; Word, Excel and Outlook
  • Confirm and schedule order delivery in Compass
7

Experience For Rn-utilization Management Nurse Resume

  • Intake and outreach calls to health care agencies when appropriate
  • Intake and outreach calls to doctor's offices
  • Discuss insurance benefits, co-pay and co-pay assistance with patients
  • Monitor and update accommodation codes and patient types (observation/inpatient), to ensure capture of status and level of care
  • The attending physician is contacted to clarify the level of service and/or the severity of illness, if this information is not clearly reflected in the patient progress notes. When continued inpatient stay cannot be justified and a plan for appropriate level of care is not implemented notify the CM physician advisor for a 2 nd level review. 2 of 3
  • Consults and lends expertise to other internal and external parties in the coordination and administration of the utilization/benefit management function
  • Reviews clinical information, applies the appropriate medical necessity criteria, policies, procedures, third party information and clinical judgment to render coverage determinations and recommendations; documents information in the current electronic system
  • Assesses the member’s progression towards anticipated outcomes; communicates and coordinates with the health care team to intervene when progression is stalled or diverted
  • Validates admission and continuing stay criteria with Primary Care Physicians, Attending Physicians, Physician Advisors and third party payers; recommends alternative levels of care and/or care sites when appropriate
8

Experience For Senior Utilization Management Nurse RN Resume

  • Participates in and follows through on interventions identified in Health Services rounds
  • Computer proficient in Word, Excel, Outlook and PowerPoint
  • Enters patient insurance authorizations and any pertinent information from insurance company into the patient account history
  • Documents insurance coverage of services to be provided
  • Manages denials or potential denials as described by insurer
  • Researches cases and applies medical criteria and clinical judgment to evaluate and render determinations for authorization requests for medical services
  • Refers cases that require additional expertise and all denials to the Medical Director for review
9

Experience For Utilization Management Nurse Rn-ridgeland Resume

  • Ensures provider and facility requests are processed appropriately in the clinical IT platform by clinical support associates, including data entry accuracy and timeliness of requests
  • Reviews clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate
  • Establishes effective rapport with other department associates, professional and support service associates, customers, clients, members, families and physicians
  • Uses effective relationship management, coordination of services, resource management, education, patient advocacy, plan policy and related interventions to:a. Promote improved quality of careb
  • Promote cost effective medical outcomesc
10

Experience For Utilization Management Nurse Case Management Resume

  • Authorize plan benefits according to policy and medical criteriad
  • Prevent hospitalizations when possible and appropriatee
  • Promote decreased length of hospital stay as appropriatef
  • Provide for continuity of careg
  • Assure appropriate level of care is provided
  • Provides advice and counsel to precertification nurses and clinical support associates
  • Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing cases to fully utilize all available resources according to the plan document
  • Tracks and monitors metrics as defined by plan administration and provides reports as needed

List of Typical Skills For an Utilization Management Nurse Resume

1

Skills For Utilization Management Nurse Consultant Resume

  • Strong computer skills (Microsoft Outlook, Word, Window Systems)
  • Verbal and written effective communication skills are required
  • Effective communication skills, both verbal and written are required
  • Prior clinical experience preferably in an acute care, skilled or rehabilitation
  • Utilizes effective interpersonal communication skills across department, campus and within the UM department
  • Healthcare experience; 2+ years Utilization Management / Review experience at a Managed Care Plan or Provider Organization
2

Skills For Utilization Management Nurse Associate Resume

  • Utilize technical skills to multitask through multiple systems at a rapid pace in order to process Precert requests timely and accurately
  • Effectively negotiate with internal and external providers of patient care services
  • Customer service, conflict resolution, and technological navigation skills required
  • Clinical experience (hospital experience); required
  • Work effectively with all departments and all levels of CHOP professionals. 
  • Effectively negotiate with internal and external providers of patient care services. 
  • Clinical experience required Managed care experience; required
  • Clinical experience required (Hospital experience)
3

Skills For Utilization Management Nurse Rn-telecommute Resume

  • Previous experience with Admissions, Utilization Review, and/or Discharge Planning
  • Experience in a post acute setting required
  • Utilization review and/ or discharge planning experience; required
  • Medical Surgery, Heart, Lung or Critical Care Nursing experience required
  • Previous experience in utilization management, case management, concurrent review or discharge planning
  • Previous experience in utilization management, case management and/or discharge planning required
  • Previous experience in utilization management, critical care, discharge planning and/or home health or rehab
  • Experience using Milliman (MCG) or Interqual criteria
  • Good clinical background working in a hospital
4

Skills For Utilization Management Nurse Review Specialist Resume

  • Experience working with Med professionals
  • Inpatient hospital care experience
  • Clinical experience
  • Experience in Managed Care or Case Management
  • Ensure the effective utilization of medical services through the application of nationally recognized medical necessity criteria
  • 3-5 relevant experience required
  • Utilization management experience at care plan/provider organization required
  • Case Management experience in long term care, hospital, or managed care
  • Experience in chart review
5

Skills For Telephonic Utilization Management Nurse Resume

  • Experience in a high volume community or mail order pharmacy practice environment
  • Clinical experience required
  • Or more managed care experience; Desired
  • Or more clinical experience; Required
  • Clinical experience is required
  • Clinical experience (medical/surgical preference); required
6

Skills For Utilization Management Nurse Reviewer Resume

  • Establish priorities among multiple needs, meet deadlines and maintain standards of productivity
  • Hospital experience is required
  • Hospital/clinical experience required
  • Clinical experience (med/surg, acute, cardiac, oncology); required
  • Previous experience in utilization management required
7

Skills For Rn-utilization Management Nurse Resume

  • Previous experience in utilization management and/or home health or rehab
  • Post Acute experience (SNF, rehab, etc)
  • Post Acute and Acute experience required
  • Med/Surg experience required
  • Previous Utilization Management experience required
  • Facilitating safe and efficient discharge planning
  • Completing assessments of a member's clinical condition and ongoing medical services and treatments to determine medical appropriateness
  • Rewarding position obtaining care that our members need
  • Documenting activities according to established standards
8

Skills For Senior Utilization Management Nurse RN Resume

  • Working closely with facilities and providers to meet the complex needs of the member
  • Reviewing services to assure medical necessity
  • Applying clinical expertise to assure appropriate benefit utilization
  • Reviewing cases and analyzing clinical information in conjunction with Medical Directors to determine the appropriateness of hospitalization
  • Early identification of continuing care needs to facilitate discharge to the appropriate setting and discharge planning
  • Of the day is spent utilizing clinical judgment along with criteria to ensure the member is in the appropriate setting
  • If notified of a denial or an impending denial notify the attending physician with a phone number to call for a Peer to Peer call
  • Facilitate safe and efficient discharge planning
9

Skills For Utilization Management Nurse Rn-ridgeland Resume

  • Day-to-day utilization management for inpatient and outpatient activities, utilizing approved policies, standards, and clinical criteria
  • Support hospital discharge planning efforts, transfers, coordination of care and manages utilization through appropriate review of authorization requests
  • General Business/Applying Reasoned Judgment/3+ years/ADVANCED
  • Guide the setting for medical intervention to achieve optimum length of stay for members
  • Bedside care in an acute care setting
  • Utilizes knowledge of age specific criteria for assigned areas, utilizing UM team resources specific to adult/pediatric age groups and/or specialty populations
  • New York, Texas, or California Registered Nurse (RN) license
  • Apply critical thinking and knowledge in clinically appropriate treatment, evidence based care and medical necessity criteria for appropriate utilization of services
10

Skills For Utilization Management Nurse Case Management Resume

  • Coordinate and communicate with providers, members and other parties to facilitate optimal care and treatment often collaborating with Aetna medical directors and other internal departments
  • Reviewing sevices to assure medical necessity
  • Applying clinical expertice to assure appropriate benefit utilization
  • Work closely with facilities and providers to meet the complex needs of the member
  • Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members
  • Gathers clinical information and applies the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation along the continuum of care
  • Communicates with providers and other parties to facilitate care/treatment Identifies members for referral opportunities to integrate with other products, services and/or programs Identifies opportunities to promote quality effectiveness of Healthcare Services and benefit utilization

List of Typical Responsibilities For an Utilization Management Nurse Resume

1

Responsibilities For Utilization Management Nurse Consultant Resume

  • Organization, planning, and time management skills
  • Strong med/surg clinical experience required
  • Utilizes clinical skills to support coordination, documentation and communication of medical services and/or benefit -administration
  • Advanced verbal communication and customer service skills
  • Apply case management skills to members who have been identified as high risk for hospital readmissions through telephonic case management
  • Managed Care and / or Clinical experience preferably working within Medicaid and Utilization Management
2

Responsibilities For Utilization Management Nurse Associate Resume

  • Utilization Management experience
  • Medicaid Utilization Management experience
  • BSN or equivalent experience required
  • Clinical experience required (med/surg)
  • Clinical experience required. It requires a Registered Nurse with unrestricted active license
3

Responsibilities For Utilization Management Nurse Rn-telecommute Resume

  • Clinical experience required (med/surg, ER, ICU)
  • Utilization management experience; required
  • Establish priorities among multiple needs, meet deadlines and maintain standards of productivity. 
  • Identify, plan, coordinate, and implement high quality, cost-effective alternatives to more costly care when appropriate to patient’s condition
  • If related experience
  • Navigate multiple Electronic Medical Record (EMR) systems and computer proficiency with Microsoft Office products including Word, Excel and Outlook
  • Facilitate the delivery of appropriate benefits and/or healthcare information which determines eligibility for benefits while promoting wellness activities
  • Documents and maintains accurate records of all communications and interventions
4

Responsibilities For Utilization Management Nurse Review Specialist Resume

  • Assists in population health management; collaborates with pharmacy benefit manager and stop loss carrier as needed
  • Collaborates with customer service regarding benefits and eligibility and the claims department to assist with medicalcoverage and benefit questions, according to the plan document
  • Assists in the development of clinical criteria and authorization guidelines through literature reviews and related research; creates draft documents for medical director and committee review and approval
  • Revises and updates documents as necessary
  • Responsible for ensuring accurate prior authorization process of incoming prior authorizations from providers,reviewing documentation for decision and composing correspondence to communicate clinical decisions to parties involved
5

Responsibilities For Telephonic Utilization Management Nurse Resume

  • Assists in the review of appeals cases for first level and retro authorizations
  • Collaborates to ensure accurate and timely review of appeals cases and assists in the appeal process as needed
  • Researches cases and applies medical criteria and clinical judgment to evaluate and render determinations for authorization requests for medical services.Refers cases that require additional expertise and all denials to the Medical Director for review
  • Ensures provider and facility requests are processed appropriately in the clinical IT platform by clinical support associates, including data entry accuracy and timeliness of requests.Reviews clinical information for concurrent reviews, extending the Length of Stay for inpatients as appropriate
  • Uses effective relationship management, coordination of services, resource management, education, patient advocacy, plan policy and related interventions to:a. Promote improved quality of careb. Promote cost effective medical outcomesc
  • Prevent hospitalizations when possible and appropriatee. Promote decreased length of hospital stay as appropriatef
  • Provide for continuity of careg. Assure appropriate level of care is provided
  • Provides advice and counsel to precertification nurses and clinical support associates.Identifies appropriate alternative and non-traditional resources and demonstrates creativity in managing cases to fully utilize all available resources according to the plan document
6

Responsibilities For Utilization Management Nurse Reviewer Resume

  • Serve as a facilitator for individual patient's episodes of care to ensure appropriate level of care opportunities is accessed
  • An RN or LPN license is required
  • Support of positive patient health care outcomes
  • Increased patient/health care team outcomes and satisfaction
  • Improved inpatient throughput and appropriate length of stay
  • Improved communication, awareness and adherence to regulatory requirements associated with utilization
  • Support for inappropriate level of care and decreased inpatient bed day denials
  • Continuity and coordination of care
7

Responsibilities For Rn-utilization Management Nurse Resume

  • Appropriate and timely authorization for level of care
  • Performs timely and accurate admission and continued stay review in accordance with department policy to ensure efficient use of hospital resources, timely discharge and optimal, appropriate reimbursement (includes communication with internal and external customers)
  • Collaborates and coordinates with all members of the health care team, patient and family (or significant others) to promote timely and effective communication, completion of workflow and services with regard to level of care decisions and payor decisions regarding continued stay
  • Meets department productivity and quality standards
  • Review clinical information to determine medical necessity
  • Facilitate the discharge plan to the appropriate level of care
  • Gathers clinical information and applies the appropriate medical necessity criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation/discharge planning along the continuum of care
  • Utilizes clinical experience and skills in a collaborative process to evaluate and facilitate appropriate healthcare services/benefits for members including urgent or emergent interventions (such as triage / crisis support)
  • Effective communication skills, both verbal and written, and the ability to effectively and credibly discuss routine and complex care situations with both external and internal clinicians
8

Responsibilities For Senior Utilization Management Nurse RN Resume

  • Intellectual humility, empathy, integrity, courage, and confidence to drive fair and purposeful and appropriate decisions. The ability to prioritize and effectively adapt to a fast paced changing environment
  • Position requires proficiency with computer skills which include navigating multiple systems and keyboarding
  • Collaborate with other team members to ensure the member's discharge plan is met and discuss other issues or needs
  • Intellectual humility, empathy, integrity, courage, and confidence to drive fair and purposeful and appropriate decisions
  • Telephonic utilization review of inpatient cases
  • Reviews inpatient cases for medical necessity
  • Utilizes MCG and the Medicare Benefits Manual for criteria
9

Responsibilities For Utilization Management Nurse Rn-ridgeland Resume

  • Close collaboration with care managers and the medical directors
  • Comprehensive knowledge of Microsoft Word, Outlook and Excel
  • Computer proficient with MS Office products; Word, Excel and Outlook
  • Active RN/LPN license in the state(s) in which the nurse is required to practice
  • Bilingual ; Fluent English and Spanish
10

Responsibilities For Utilization Management Nurse Case Management Resume

  • Knowledge of clinical practice norms
  • A designated home work space and access to install secure high-speed internet via cable/DSL
  • Knowledge of patient care, medical treatments and hospital procedures
  • Current licensure as a Registered Nurse in the State of Ohio at time of hire required
  • Active Tenneessee RN license
  • Licensed Practical Nurse (LPN) with unrestricted state license
  • Active and unrestricted Registered Nurse (RN) License is required
  • Work independently or within a team structure
  • Knowledge of managed care admission process (i.e. verification of benefits, admissions notification)

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