Collaborating on a daily basis with Case managers both at Carefirst and participating facilities to insure member meet criteria for continuation of care. Discharge planning, case management, care management, conducting disease management programs and appropriate referrals to disease management programs.

Knowledgeable of reimbursement guidelines.

Coordinate post-acute care needs for member with Medical Director. Consulted with Medical Director on cases with inconsistencies prior to final approval or denial. – Assesses time parameters for when patient is ready to return home.

Education and training of new and current employees in Acuity and frequently utilized applications specific to the Health Plan. Assists with the planning, development and implementation of policies, procedures and training materials; and provides NF staff and UR nurse reviews with ongoing education. Direct registry services for Nurses, Private Duty according to regulations established by state or district professional nurses association. Conducted initial, concurrent and retrospective review of inpatient admissions and outpatient ambulatory approvals for Worker's Compensation Claimants. Covering UMC and multiple skilled nursing facilities. Participated in weekly case review with medical director via phone conference.

Click here to read more. Facilitated acquisition of needed durable medical equipment and supplies for home care and coordinated follow-up appointments. Act as a resource to new and current staff members as well as outside providers to insure appropriate utilization. Respond to incoming calls within processing times and utilize pre-certification guidelines, Review surgical cases according to medical necessity using Medicare and inter-qualification guidelines, Refer pre-determinations to Medical Director as appropriate, Review medical record documentation to determine medical necessity, Apply and document Milliman criteria to support precertification, Refer cases for external initial Physician review and Appeal, Effectively communicate with Clients, Facilities, Physician Offices and Clinical staff. Assigning length of stay based on diagnosis/ICD-9, ICD-10, procedures and review necessity for ongoing hospital and skilled nursing stays, Inpatient pre-certification, concurrent and retrospective review of delivery of care and treatment in hospital setting. Responsible for online referral management requests for specialty care, elective surgeries, Treatment plans and diagnostic studies in accordance with commercial and senior health plans with emphasis on timeline criteria.

Ensures appropriate and cost-effective healthcare services to patients. Compliance with established utilization review process performance expectations and standards, assuring clients receive the highest degree of professional medical accuracy. Perform discharge planning including SNF, Acute rehab, LTAC, Sub acute placements and home care authorizations.

Review physician documentation and medical records to determine if proposed treatment plan is medically necessary and appropriate per medically accepted clinical review criteria.

Assesses and interprets customer needs and requirements. Enters billing information for services. The services that utilization review nurses provide to insurance companies, medical facilities, and patients help in keeping the healthcare industry free of any problems.

Uses advanced program knowledge and nursing expertise to evaluate medical records and perform review change to the NF's MDS assessment.

With an insurance company, they can review medical claims and find out if they should be honored or dishonored. Developed and implemented physician education tools. Reinforced policies, evaluate patient situations and weighed patients individual needs against the insurance coverage details; contributed to making final decisions on treatment, medications, surgeries and re-admissions. Provides authorizations and/or denials based on clinical documentation review and medical necessity. Provide acute care concurrent review and acute rehab reviews. Review charts of clients that are in Tucson area Hospitals. Identify, evaluate, and initiate case management on patients based on diagnosis/ referrals to Case management/Disease Management Programs.

Provide support to other departments within the Health Plan, ie: Prior Authorization, Case Management, Acuity/Cerecons implementation and staff training. Communicates results to claims adjusters. Determined approval or denial for durable medical equipment, physical/occupational therapy and home health care. Performed duties in accordance with well-established rules, procedures, regulations, principles and operations covering patient medical records, their required contents, establishment and maintenance of special registries, documentation of incidents, and diagnostic coding requirements and procedures.

7,846 Utilization Review Nurse jobs available on Responsible for requesting clinical information for concurrent review with strict adherence to URAQ guidelines, Responsible for presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging any peer-to-peer reviews, if requested by hospitalist, attending, or primary care physician, Assisted and/or provided facility interdisciplinary teams benefit information for in network providers/facilities, DME, home healthcare, acute, sub-acute rehab, skilled nursing facilities, and out-of-network benefits, if needed, Communicated frequently with assigned case managers for unplanned admissions, inpatient status, and discharge plan with orders, Collaborated with assigned case manager to identify members frequent hospital readmissions, Participated in weekly UM Grand Rounds with plan liaison, medical director, URNs and Alere oncology medical director.

Perform telephonic case management on discharged patients to assess needs in the home, follow up with physicians and trouble shoot in order to deliver appropriate and timely care and prevent readmissions.

Nursing expertise in monitoring NFs placed on corrective actions, as a result of inaccurate MDS assessments. Provided approval for emergency and scheduled hospital admissions based on the medical necessity and standard criteria, Identified and coordinated discharge needs and transfers to a lower level of care. Identified and coordinated services both internally and externally; interacted extensively with case managers and physicians to determine follow-up care needs for discharged patients.

Studied and learned Interqual Criteria System. Work from home based position in Pensacola area.

Conducted telephonic reviews using Interqual criteria to support the need for admission and/or extension of inpatient stay.

Maintaining close relationships among all parties, in person and telephonically, Performed telephonic prospective, concurrent & retrospective reviews for inpatients & outpatients for approximately 30. Oversight of patient care and medical needs via AHCCS standards, Ensure patient transfers are appropriately handled by facilities and their staff, Coordinate all discharge planning activities, Evaluate charts of patients to make sure they meet inpatient criteria per facility standards. Utilization Review Nurses' resumes reflect a bachelor's degree in nursing, as well as registered nurse licensure and post-baccalaureate certificates in the fields of health care risk management or case management. Demonstrated knowledge of Millman and Interqual criteria.

Reviewed and evaluated medical records for in-patient admissions to determine if required documentation was present. Registration, review and authorization of inpatient hospital and skilled nursing stays using daily review information consisting of treatments and delivery of care based on medical necessity.

Find out what is the best resume for you in our Ultimate Resume Format Guide. Utilization Review Nurse for Nexus Medical Consulting.

Obtained required credentials as a Certified Professional in Utilization Review, developed the program, provided training to physicians and other clinic staff then implemented Utilization Review and Case Management programs for the clinic.

Medical records review and determination of days based on Milliman Care Guidelines. Receives and processes requests for appeal of denials.

Worked with Amisys, TruCare and RightFax software. Participated in multi-disciplinary case management/discharge planning at community hospitals for hospitalized active duty members. To ensure the effective and efficient use of health care services. With a hospital, they will help both patient and the facility with their analysis skills and determine whether the patient needs to … Promptly identify inconsistencies and make recommendations to management for action. There are plenty of opportunities to land a Utilization Review Nurse job position, but it won’t just be handed to you. Collaborate with regional and state office staff related to any sanctions or other actions to be taken regarding contract non-compliance. Proactively educated physicians and patient/caregivers regarding vendor and community service resources. Followed patients from admission to discharge, making sure the current level of care was optimal; communicated necessary moves from acute care to less intensive setting at appropriate intervals. Working under the guidelines of Acute Care vs Skilled Nursing Rehab insuring members are meeting the criteria for proper level of care to meet their current Rehab needs. Maintained statistical records and quarterly reports as required.

Home based position using company supplied equipment including laptop and printer.

Provided daily utilization review and decisions for the HMO and FlexCare populations of Cigna HealthCare. – Contacted average of 10 insurance companies each week.

Experienced in working in a managed care environment. Participated in WebEx meetings for information distribution and educational needs. Determined whether all aspects of patient care, at every level, to be medically necessary and appropriate.

Collaborated with multidisciplinary teams.

Utilization Review Nurses review patient cases and ensure that the patient is receiving the proper treatment.

Assisted with the Appeals and Grievance process.

Worked with insurance companies to determine allowable coverage; reviewed surgery and elective procedure schedules to make determinations on reimbursement rates. Care coordination and discharge planning. Present oral case presentations daily to Physician Reviewer, Perform discharge planning, including home health, nursing home placement, rehabilitation, and assistance with community resources, Review clinical information for medical necessity and appropriate level-of-care for patients admitted to the hospital, Review clinical information for concurrent reviews, extending the length of stay for inpatients as appropriate. ● Evaluated the progress of each patient and provided updates to insurance providers● Performed utilization reviews in accordance with state and federal regulations● Attended meetings with medical staff to finalize patient discharge plans● Responded to calls and emails from insurance providers● Assessed the physical and mental status of each patient● Coordinated in-hospital and outpatient care arrangements.

Specialize in finding a balance between the fiscal needs of the hospital or medical facility and the care needs of each patient. December 2010 to February 2012 Transitional Care for Seniors Health Care Facility – Cobbler, GA Utilization Review Nurse – Worked with insurance companies to provide list of expected patient care services. Entering information via computer system approving medical criteria to insure payment of claims in a timely manner. Documentation must be grammatically correct with proper punctuation, capitalization and grammar. recommend certification of proposed treatment plan and issue authorization letters, or if not supported, refer for peer clinical review physician.

Reviewed medical records for ICD 9, CPT and DRG. Maintain communications with the payer at the time of admission and throughout the hospitalization to ensure necessary approvals for care and clarification of benefits, Monitor for appropriateness of admission, stay and readiness for discharge based on criteria as evidence by appropriate documentation and Interqual, Complete retrospective reviews for Behavior Medicine Units to obtain approval of care, Processed paperwork for active duty military personnel, their dependents and retirees for admission to VHC's addictions and rehabilitation program utilizing their Tricare benefit, Current Team leader over 5 co-workers, daily assignments, and assist with supervisor delegation of duties, Case management 20 to 30 inpatient hospital stays, Discharge planning and utilization of Milliman and Roberts software, Work on weekend team, post hospital discharge calls, Transition patient care to lesser setting SNF, LTACH, home care, Work directly with hospital case management to coordinate patient care, Special assignments such as employee management and weekend/discharge appeals programs.

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