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Utilization review nurse skills for your resume and career
15 utilization review nurse skills for your resume and career
1. Medical Necessity
- Reviewed medical records of hospitalized patients/members of the Health Plan to determine medical necessity and appropriateness of admissions and continued stays.
- Performed review primarily for intensive care, long-term acute, and medical-surgical units to determine medical necessity and facilitate discharge coordination.
2. Patients
- Review medical documentation submitted by physicians treating patients injured after motor vehicle accidents to determine if treatment is medically necessary.
- Identify, evaluate, and initiate case management on patients based on diagnosis/ referrals to Case management/Disease Management Programs.
3. Acute Care
The branch of secondary healthcare which is responsible for giving short-term care to patients recovering from severe injuries or urgent medical problems is known as acute care. Acute care comprises multiple domains like; emergency care, urgent care, short-term stabilization, pre-hospital care, critical care, and trauma care.
- Reviewed clinical information submitted by acute care facilities to determine placement in a Skilled Care Facility for post hospitalization treatment.
- Analyzed acute care medical records to determine appropriate payment reimbursement for inpatient and outpatient services.
4. Discharge Planning
- Maintained responsibility of interfacing with physicians, nurses, social services, and health equipment providers to ensure effective admission/discharge planning.
- Participated in discharge planning process with hospital and inpatient facility staff, ensuring adequate and appropriate disposition and post discharge plans.
5. Utilization Management
- Document appropriately using established Utilization Management policy.
- Managed functions related to developing and maintaining delegation of Care Management activities such as Ambulatory Referral Management and Full Utilization Management.
6. Utilization Review
Another name for utilization review is utilization management. It is the process of ensuring that healthcare services are used in a suitable manner. Utilization review is a critical component of adding value to the health care system. Mostly, UR is carried out by healthcare insurance companies, but hospitals and other healthcare providers also perform the process. Utilization review has three types of assessment namely: concurrent, prospective, and retrospective.
- Provided ongoing customer service and education, specifically instructing on plan requirements for Utilization Review and directing customers to appropriate resource.
- Conducted clinical review for medical necessity of Workers compensation claims based on state regulatory guidelines and Utilization Review Accreditation Committee.
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Community resources are a set of resources that are used in the day to day life of people which improves their lifestyle in some way. People, sites or houses, and population assistance can come under the services offered by community resources.
- Establish and maintain a relationship of collaboration with physicians, hospital departments and community resources to facilitate communication regarding patient care.
- Assured community resources are provided and support participants through process of accessing community resources and continuum of care.
8. Outpatient Services
- Conducted reviews for medical appropriateness of inpatient and outpatient services using appropriate criteria after benefit determination, if applicable.
- Determine medical appropriateness of inpatient (elective) and outpatient services following evaluation of medical guidelines and benefit determination.
9. Clinical Knowledge
Clinical knowledge is defined as the complete body of information about diseases, pathology, treatments, drugs, mechanisms, pathogenesis, therapies, interactions, contraindications, and interpretation of lab tests and reports which is helpful in devising a diagnosis and treatment plan for a given patient.
- Utilize clinical knowledge to properly adjudicate Worker's Compensation medical and facility bills.
- Utilized clinical knowledge to determine if physician review of requests were necessary
10. Home Health
- Conducted analysis of home health utilization patterns and developed process improvements.
- Review Medicare Home Health claims to determine patient eligibility.
11. Patient Care
Patient care entails the diagnosis, recovery, and control of sickness as well as the maintenance of physical and emotional well-being through the use of healthcare providers' services. Patient care is described as services provided to patients by health practitioners or non-professionals under guidance.
- Monitored patient care documentation for patient progress towards treatment objectives and related this information to payers and appropriate others.
- Gathered, requested, and communicated information regarding patient care and communicated requests from insurance/managed care companies when appropriate.
12. Appeals
- Reviewed and investigated member and provider requests and appeals to determine appropriate utilization of benefits and/or claim adjudication.
- Applied medical knowledge and clinical expertise in reviewing medical claims, subscriber/provider inquiries and appeals.
13. CPT
CPT is a medical term that stands for Current Procedural Terminology. Whenever a procedure like surgery or diagnosis occurs or some other medical service is rendered to a patient, it is reported to the concerned physician, insurance company, or organization. The aforementioned practice is widely referred to as CPT.
- Possessed the ability to navigate quickly through the ICD9, CPT and HCPIC manuals to verify correct coding and billing practices.
- Advised insurance carriers on recommended reimbursement for charges following automated bill audit utilizing ICD-9 and CPT codes.
14. Medical Directors
- Coordinate with Medical Directors and independent physician reviewers to determine appropriate treatment per guidelines and employer's summary plan descriptions.
- Referred appropriate cases to medical directors, supervisors and/or cosmetic surgery section for review and decision making.
15. Clinical Judgment
- Utilize clinical judgment with clinical guidelines to determine when referring to the Medical Director for those authorizations requiring additional expertise.
- Obtain clinical information to apply the appropriate clinical criteria/guideline, policy, procedure and clinical judgment to render coverage determination/recommendation.
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What skills help Utilization Review Nurses find jobs?
Tell us what job you are looking for, we’ll show you what skills employers want.
What utilization review nurse skills would you recommend for someone trying to advance their career?
Jordan Porter DNP, APRN, FNP-BC
Lecturer of Nursing, University of Maine
What hard/technical skills are most important for utilization review nurses?
Cherie Burke Ph.D.
Director of the School of Nursing, Associate Professor, Loyola University New Orleans
-Strong nursing background
-Knowledge of evidence-based resources and practices
List of utilization review nurse skills to add to your resume
The most important skills for a utilization review nurse resume and required skills for a utilization review nurse to have include:
- Medical Necessity
- Patients
- Acute Care
- Discharge Planning
- Utilization Management
- Utilization Review
- Community Resources
- Outpatient Services
- Clinical Knowledge
- Home Health
- Patient Care
- Appeals
- CPT
- Medical Directors
- Clinical Judgment
- Medical Care
- Clinical Review
- Chart Review
- Proactive Planning
- HIPAA
- Social Work
- CMS
- Concurrent Review
- Health Care Services
- Inpatient Admissions
- Health Plan
- ICD-9
- Interqual Criteria
- Medicare
- Medicaid
- Retrospective Reviews
- Clinical Documentation
- Excellent Interpersonal
- Data Collection
- Medical Services
- HCPCS
- Rehabilitation
- DRG
- Data Entry
- Strong Computer
- Medical Policy
- SNF
- NCQA
- HMO
- Physician Review
- Medical Claims
- Compassion
- Clinical Criteria
- Clinical Guidelines
- HEDIS
Updated January 8, 2025
