Below we've compiled a list of the most important skills for a utilization review nurse. We ranked the top skills based on the percentage of utilization review nurse resumes they appeared on. For example, 15.9% of utilization review nurse resumes contained utilization review as a skill. Let's find out what skills a utilization review nurse actually needs in order to be successful in the workplace.

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The six most common skills found on Utilization Review Nurse resumes in 2020. Read below to see the full list.

15 Essential Utilization Review Nurse Skills For Your Resume And Career

1. 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.

Here's how utilization review is used on utilization review nurse resumes:
  • Provided ongoing customer service and education, specifically instructing on plan requirements for Utilization Review and directing customers to appropriate resource.
  • Champion adequate utilization review nurse staffing to optimize recovery of managed care case insurance claims as an effective cost-saving strategy.
  • Perform utilization review on national Worker's Compensation and private insurance cases for medical necessity and adherence to guideline recommendations.
  • Provided guidance and coaching to other utilization review nurses and participated in the orientation of newly hired utilization nurses.
  • Contract Position Performed Prior Authorization and Utilization Review of Home Health Services and Durable Medical Equipment for Medicaid recipients.

2. Medical Records

Here's how medical records is used on utilization review nurse resumes:
  • Review and interpret medical records for concurrent and retro hospital admissions utilizing and applying InterQual criteria to determine level of care.
  • Reviewed medical records of hospitalized patients/members of the Health Plan to determine medical necessity and appropriateness of admissions and continued stays.
  • Verify medical records and authorization requests from providers, hospitals, and medical facilities by utilizing InterQual criteria and clinical experience.
  • Review physician and medical records to determine if proposed treatment plan is medically necessary and appropriate per accepted clinical review criteria.
  • Analyze claims and medical records documentation for medical necessity and program compliance of Medicare benefit coverage, coding and documentation requirements.

3. Treatment Plans

A treatment plan is a detailed plan created by a physician or a medical expert that contains all the necessary information about a patient. It would contain the entire medical history of the patient, along with information on the patient's disease, its treatment, and how it should be executed. The treatment plan contains information about the treatment and its possible side effects. It may also contain the cost of the treatment and the necessary precautions that should be taken after it.

Here's how treatment plans is used on utilization review nurse resumes:
  • Conducted certification, concurrent and retrospective reviews of patient's inpatient and outpatient hospital treatment plans.
  • Review proposed hospitalization, managed care, and in-patient/out-patient treatment plans for medical necessity.
  • Participated in treatment planning meetings to discuss individual patient treatment plans with interdisciplinary staff.
  • Review treatment plans for medical necessity referring to Medical Director Review if necessary.
  • Talked to Case Managers from the hospital to obtain treatment plans to help get Patients stay in the Hospital if needed.

4. 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.

Here's how patient care is used on utilization review nurse resumes:
  • Establish and maintain a relationship of collaboration with physicians, hospital departments and community resources to facilitate communication regarding patient care.
  • 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.
  • Developed criteria for the ongoing systematic monitoring and evaluation of patient care utilization to include tracking appropriate data.
  • Demonstrated awareness of and adherence to Naval Hospital policies and procedures to ensure quality patient care was provided.

5. 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.

Here's how acute care is used on utilization review nurse resumes:
  • Reviewed clinical information submitted by acute care facilities to determine placement in a Skilled Care Facility for post hospitalization treatment.
  • Coordinated the transfer of patients to community skilled nursing facilities, rehabilitation centers and other acute care facilities.
  • Collaborate with Case Managers for discharge planning and smooth transition for patients post -acute care in the most appropriate setting.
  • Include a plan of care that specifically describes why the patient continues to require hospitalization in an acute care hospital.
  • Conduct clinical reviews for acute care hospital admissions utilizing CMS guidelines, MCG criteria as well as clinical experience.

6. Clinical Staff

The clinical staff consists of people who work under a healthcare professional like a physician. Their job is to assist in healthcare professional services but not to report them directly. The clinical staff has direct contact with patients for diagnosis, treatment, and further care.

Here's how clinical staff is used on utilization review nurse resumes:
  • Documented clinical information as related to the clinical condition and in support of the criteria selected to justify authorization of services.
  • Reviewed completed decisions for verification of accuracy of submitted clinical information and entered any corrections, clarifications or additional information.
  • Review clinical information for medical necessity according to above protocols and follow for alternative home care for Physical/Occupational/Speech Therapies.
  • Utilize clinical information and knowledge of medical necessity criteria to effectively communicate plans of care to insurance case manager.
  • Coordinated the utilization management decision-making process by gathering relevant clinical information and regulatory guidelines on each case.

7. Communication

Communication is the ability to express one's ideas and thoughts to other people using expressions, words, or actions. Communication is to receive or send any kind of information. People need to be able to communicate and convey their message to the customers to run a successful business.

Here's how communication is used on utilization review nurse resumes:
  • Maintained communication with the medical director -daily report of inpatient acuity level per InterQual criteria, reviewed and assessment of criteria.
  • Initiated timely communication with insurance companies to obtain authorization for hospitalizations and advanced imaging to achieve the maximum allowable reimbursement.
  • Review patient charts for Medicare and Medicaid Reimbursement* Schedule my own jobs* Communication with area facilities to schedule appointments* Work Independently
  • Provide ongoing communication with health plan utilization departments regarding medical necessity for prospective, concurrent, and retrospective reviews.
  • Created and documented clinical synopses of medical case reviews to support determination using critical thinking and written communication skills.

8. Community Resources

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.

Here's how community resources is used on utilization review nurse resumes:
  • Assured community resources are provided and support participants through process of accessing community resources and continuum of care.
  • Coordinated mental health services with clinics, specialized units, affiliated private agencies and available community resources.
  • Perform discharge planning, including home health, nursing home placement, rehabilitation, and assistance with community resources.
  • Assisted in providing medical care needed, equipment, support for family members and assistance with community resources.
  • Identify and obtain needed community resources and provide feedback to external agencies on cases as necessary.

9. Ensure Compliance

Ensure compliance means that all the standards that have been set are being maintained. Making sure that all the policies are being followed also assists in ensuring compliance.

Here's how ensure compliance is used on utilization review nurse resumes:
  • Review cases to ensure compliance with Medicare/Medicaid rules and regulations including delivering mandatory information to patients regarding their admission.
  • Authorized treatment when appropriate and medically necessary and coordinated with medical providers to ensure compliance.
  • Visited medical practices and collecting sensitive patient health information to ensure compliance with insurance companies.
  • Documented regional significant improvements to ensure compliance with NCQA requirements.
  • Performed daily concurrent review on all in-patient admissions to ensure compliance and adherence to Quality Measures per CMS guidelines and specifications.

10. 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.

Here's how clinical knowledge is used on utilization review nurse resumes:
  • 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
  • Maintain a medical/clinical knowledge base that is consistent with current medical practices, trends, and patterns of care.
  • Applied clinical knowledge and nursing judgment for case review of medical necessity using appropriate criteria.
  • Make quality review decisions utilizing InterQual criteria, PAS LOS standards and clinical knowledge.

11. Outpatient Services

Here's how outpatient services is used on utilization review nurse resumes:
  • Evaluate and authorize inpatient and outpatient services based on medical necessity applying approved criteria for both commercial and Medicare plans.
  • Perform UM reviews (prospective/concurrent/retrospective) for inpatient/outpatient services according to the URAC standards and client requirements and/or policies.
  • 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.
  • Evaluate requested outpatient services for medical necessity and setting, search for appropriate participating providers and negotiate rates.

12. Health Care

Healthcare means an organized service provided to people when they are diagnosed with a medical illness or suffer an injury. Basic health care would ensure to improve the health of the patient. Health care is provided by designated and certified specialists who can be doctors, registered nurses, therapists, etc. The healthcare of the people is the responsibility of the state as they set up hospitals and clinics for the public and arrange certified professionals in them for the health care of the people.

Here's how health care is used on utilization review nurse resumes:
  • Provide telephonic discussion with health care providers and/or members to explain benefit courage determinations and to obtain additional clinical information.
  • Performed retrospective review to determine reasonableness and necessity of health care services delivered to individuals who had sustained accidental injury.
  • Utilize decision-making and critical thinking skills in the review and determination of coverage for medically necessary health care services.
  • Educated subscribers regarding the Case Management program and effective utilization of health care benefits and services.
  • Interpreted and applied health care industry and federal regulations regarding data compliance requirements for health professionals.

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.

Here's how cpt is used on utilization review nurse resumes:
  • Possessed the ability to navigate quickly through the ICD9, CPT and HCPIC manuals to verify correct coding and billing practices.
  • Conducted concurrent and retro utilization review, quality indicators review, and used ICD 9 and CPT codes.
  • Review of provider medical record documentation for compliance with CPT and ICD-10 coding guidelines and AHCCCS/Medicare benefits.
  • Advised insurance carriers on recommended reimbursement for charges following automated bill audit utilizing ICD-9 and CPT codes.
  • Review of clinical information via internet, fax and phone for determination of ICD-9 and CPT codes.

14. Clinical Judgment

Here's how clinical judgment is used on utilization review nurse resumes:
  • 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.
  • Forwarded appropriate requests to the Medical Director with recommendations for determinations using approved guidelines and clinical judgment.
  • Used clinical judgment and completed reviews using CMS guidelines outlined in the QIO and used InterQual only for complex cases.
  • Perform weekly reviews of patient's progress with skilled therapy using clinical judgment.

15. Medical Directors

Here's how medical directors is used on utilization review nurse resumes:
  • 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.
  • Collaborate with internal and external medical colleagues and Medical Directors in order to maintain a timely process.
  • Communicate and provide recommendations/feedback to the medical directors regarding complex, high utilization, and specialty cases.
  • Partnered with medical directors to determine medical necessity of requested radiology studies by applying clinical guidelines.

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Online Courses For Utilization Review Nurses

One of the best ways to acquire the skills needed to be a utilization review nurse is to take an online course. We've identified some online courses from Udemy and Coursera that will help you advance in your career. Since utilization review nurses benefit from having skills like utilization review, medical records, and treatment plans, we found courses that will help you improve these skills.

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Pediatric HIV Nursing
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Taught by leading experts in pediatric HIV clinical care and treatment, nursing, and global health, this course will equip nurses and midwives with the skills they need to provide quality clinical care to children living with HIV according to the latest clinical guidelines from the World Health Organization. The course is self-paced to accommodate individual schedules and learning needs.ICAP at Columbia University has been a leader in international HIV care and treatment for over a decade. We...

CERTaIN: Knowledge Synthesis: Systematic Reviews and Clinical Decision Making
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Discover practical ways to critically appraise scientific literature, including the conduction and interpretation of systematic reviews and meta-analyses. Additionally, you will learn how to conduct literature searches using online academic databases, hear about economic evaluations, and understand how clinical practice guidelines are used to guide decision making. This course includes the following 11 lectures: Overview of Systematic Reviews Finding and Managing the Evidence from the...

Medical Terminology

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Most Common Skills For Utilization Review Nurses

RankascdescUtilization Review Nurse SkillascdescPercentageascdesc
Utilization Review
Medical Records
Treatment Plans
Patient Care
Acute Care
Clinical Staff
Community Resources
Ensure Compliance
Clinical Knowledge
Outpatient Services
Health Care
Clinical Judgment
Medical Directors
Chart Review
Appropriate Level
Inpatient Admissions
Insurance Companies
Clinical Documentation
Data Collection
Data Entry
Medical Policy
Physician Review
Clinical Guidelines
Clinical Criteria
Social Workers
Medical Equipment
Disease Management
Clinical Trials
Hospital Admissions
Medical Appropriateness
Complex Cases
Outpatient Procedures
Hospital Stay

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