Utilization Review Nurse Resume Examples

Utilization Review Nurse Resume Examples

Below is a professionally crafted Utilization Review Nurse resume sample. This example adheres to best practices in resume writing, showcasing a clear, concise, and impactful presentation of qualifications. It serves as a guide for nurses seeking to advance their careers in utilization management and review.

Jane M. Anderson, RN, BSN, CCM

1234 Elmwood Drive
Chicago, IL 60614
Phone: (312) 555-7890
Email: [email protected]
LinkedIn: linkedin.com/in/janemandersonrn

Professional Summary

Highly detail-oriented Utilization Review Nurse with over 7 years of experience in clinical case management and healthcare utilization evaluation. Proven expertise in coordinating care, ensuring compliance with payer guidelines, and collaborating with multidisciplinary teams to optimize patient outcomes. Certified Case Manager (CCM) committed to balancing cost control with quality care delivery. Exceptional analytical and communication skills support effective decision-making and stakeholder engagement.

Core Competencies

1. Clinical Utilization Review
2. Case Management and Coordination
3. Insurance and Payer Guidelines Compliance
4. Medical Record Analysis
5. Interdisciplinary Team Collaboration
6. Patient Advocacy and Education
7. Electronic Health Record (EHR) Systems
8. Quality Improvement Initiatives
9. Regulatory Compliance (CMS, URAC)

Professional Experience

Utilization Review Nurse
Northwestern Memorial Hospital, Chicago, IL
June 2018 – Present

– Conduct thorough reviews of inpatient and outpatient medical records to assess appropriateness of care based on established clinical criteria and insurance coverage policies.
– Collaborate with physicians, case managers, and insurance representatives to facilitate timely authorization and discharge planning, reducing unnecessary hospital stays by 15%.
– Monitor utilization patterns and generate detailed reports to inform hospital quality improvement efforts and ensure regulatory compliance.
– Lead education sessions for clinical staff regarding utilization management procedures and documentation requirements, enhancing accuracy and efficiency.
– Utilize Epic EHR system to track patient progress and document review outcomes, ensuring seamless communication across care teams.

Case Management Nurse
Johns Hopkins Hospital, Baltimore, MD
August 2014 – May 2018

– Managed complex case loads involving chronic disease management, coordinating services across multiple providers and community resources.
– Performed utilization reviews to support insurance approvals for interventions and durable medical equipment, achieving a 98% approval rate through accurate clinical documentation.
– Facilitated patient discharge planning by identifying barriers and coordinating post-discharge services, resulting in a 20% reduction in readmission rates.
– Participated in multidisciplinary team meetings to develop individualized care plans tailored to patient needs and payer requirements.

Education

Bachelor of Science in Nursing (BSN)
University of Illinois at Chicago, Chicago, IL
Graduated May 2014

Certifications

Certified Case Manager (CCM)
Commission for Case Manager Certification
Issued July 2016 | Active

Registered Nurse (RN) License
Illinois Board of Nursing
Active since 2014

Professional Affiliations

American Case Management Association (ACMA)
Member since 2015

Technical Skills

– Epic Systems
– Cerner EHR
– Utilization Review Software (MModal, InterQual)
– Microsoft Office Suite (Word, Excel, PowerPoint)

References

Available upon request

This utilization review nurse resume example demonstrates a balance of clinical expertise, regulatory knowledge, and communication skills essential for the role. Tailoring your resume to highlight measurable achievements and relevant certifications will distinguish you in this competitive field.

Utilization Review Nurse Resume Examples

Below is a professionally crafted Utilization Review Nurse resume example designed to showcase the essential skills, education, and experience sought by healthcare employers. This sample reflects best practices in resume writing, balancing clarity, formality, and engagement.

Jane M. Thompson, RN, BSN, CCM

123 Elmwood Drive, Chicago, IL 60614
Phone: (312) 555-7890 | Email: [email protected] | LinkedIn: linkedin.com/in/janemthompson

Professional Summary

Dedicated and detail-oriented Utilization Review Nurse with over seven years of experience in acute care and managed care environments. Proven expertise in clinical case review, authorization processes, and interdisciplinary collaboration to optimize patient care and resource utilization. Certified Case Manager (CCM) with a strong commitment to regulatory compliance and quality improvement initiatives.

Core Competencies

1. Utilization Review & Authorization
2. Clinical Documentation Improvement
3. Medical Necessity Determination
4. Interdisciplinary Team Collaboration
5. Case Management & Discharge Planning
6. Regulatory Compliance (JCAHO, CMS)
7. Electronic Medical Records (EMR) Proficiency
8. Patient Advocacy & Education

Professional Experience

Utilization Review Nurse
Northwestern Memorial Hospital, Chicago, IL
June 2018 – Present
– Conduct comprehensive medical record reviews to evaluate the appropriateness of inpatient and outpatient services, ensuring alignment with payer guidelines and clinical protocols.
– Collaborate with physicians, case managers, and insurance representatives to facilitate timely authorizations and appeals, reducing delays in patient care.
– Utilize EMR systems to document findings and track utilization metrics, contributing to quarterly reports presented to hospital administration.
– Participate in quality improvement committees aimed at reducing length of stay and readmission rates by 15% over two years.
– Train junior nurses and staff on utilization review standards and compliance requirements.

Case Management Nurse
Kaiser Permanente, Oakland, CA
August 2014 – May 2018
– Managed complex patient cases through comprehensive assessment, care planning, and coordination of services across multiple specialties.
– Reviewed clinical documentation to ensure medical necessity, supporting efficient resource allocation and cost containment.
– Coordinated discharge planning with social workers and community agencies to promote smooth transitions of care.
– Maintained compliance with CMS and state regulatory standards, contributing to the facility’s successful accreditation surveys.
– Developed patient education materials to enhance understanding of care plans and treatment options.

Education

Bachelor of Science in Nursing (BSN)
University of Illinois at Chicago, Chicago, IL
Graduated May 2014

Certifications

Certified Case Manager (CCM), Commission for Case Manager Certification, 2017 – Present
Registered Nurse (RN), Illinois State Board of Nursing, Active License

Professional Affiliations

American Case Management Association (ACMA)
American Nurses Association (ANA)

Technical Skills

Epic Systems, Cerner, Meditech, Microsoft Office Suite

For healthcare employers seeking a Utilization Review Nurse who combines clinical expertise with administrative acumen, Jane M. Thompson exemplifies a candidate capable of enhancing patient outcomes while maintaining cost-effective care delivery.

References available upon request.

Utilization Review Nurse Resume Examples

Jane M. Holloway, RN, BSN, CCM

Los Angeles, CA | (555) 123-4567 | [email protected] | LinkedIn: linkedin.com/in/janehollowayrn

Professional Summary

Experienced Utilization Review Nurse with over 8 years in acute care and insurance settings, specializing in clinical documentation review, case management, and regulatory compliance. Adept at coordinating between healthcare providers and payers to optimize patient outcomes while ensuring cost-effective care delivery. Certified Case Manager (CCM) with a solid foundation in evidence-based practice and healthcare quality standards. Committed to thorough clinical assessment and effective communication.

Core Competencies

1. Utilization Management & Review
2. Case Management & Coordination
3. Clinical Documentation Improvement
4. Regulatory Compliance (JCAHO, CMS)
5. Interdisciplinary Team Collaboration
6. Electronic Medical Records (EMR) Systems
7. Patient Advocacy & Education
8. Data Analysis & Reporting

Professional Experience

Senior Utilization Review Nurse
Kaiser Permanente, Los Angeles, CA
June 2018 – Present

– Conduct comprehensive reviews of inpatient and outpatient medical records to determine medical necessity and appropriateness of care, ensuring alignment with organizational policies and payer guidelines.
– Collaborate with physicians, case managers, and payers to facilitate timely discharge planning and transitions of care, reducing readmission rates by 15% over two years.
– Lead education sessions for clinical staff on utilization review processes and documentation best practices, improving compliance by 20%.
– Utilize EMR systems (Epic, Cerner) to extract relevant clinical data and prepare detailed reports for utilization committees and regulatory audits.
– Maintain up-to-date knowledge of healthcare regulations including Medicare, Medicaid, and private insurer requirements, ensuring continuous compliance.

Utilization Review Nurse
Blue Cross Blue Shield of Michigan, Detroit, MI
August 2014 – May 2018

– Reviewed and authorized medical claims for inpatient admissions, outpatient procedures, and durable medical equipment requests, balancing cost containment with quality care delivery.
– Conducted concurrent and retrospective reviews to assess the necessity of services, contributing to a 12% decrease in unnecessary hospital days.
– Communicated effectively with providers and members to clarify clinical information and expedite approvals.
– Participated in multidisciplinary utilization review committees to develop and refine clinical criteria.
– Supported case managers by providing detailed clinical insights to guide patient care plans.

Registered Nurse – Medical-Surgical Unit
Johns Hopkins Hospital, Baltimore, MD
July 2011 – July 2014

– Delivered direct patient care to a diverse population with complex medical conditions in a fast-paced tertiary care environment.
– Monitored patient progress, documented clinical findings, and collaborated with interdisciplinary teams to develop individualized care plans.
– Assisted in discharge planning and patient education, promoting adherence to treatment regimens and follow-up care.

Education

Bachelor of Science in Nursing (BSN)
University of Michigan School of Nursing, Ann Arbor, MI
Graduated May 2011

Certifications

Certified Case Manager (CCM)
Commission for Case Manager Certification, 2017 – Present

Registered Nurse (RN) License
California Board of Registered Nursing, Active

Professional Affiliations

American Case Management Association (ACMA)
Member since 2016

Technical Skills

Epic, Cerner, Meditech, Microsoft Office Suite, Utilization Review Software

References

Available upon request.

This resume example demonstrates a balanced approach to showcasing clinical expertise, utilization review proficiency, and collaborative skills. The clear structure and concise language ensure readability while highlighting key qualifications sought by healthcare organizations.

Utilization Review Nurse Resume Examples

Jane M. Collins, RN, BSN, CCM

Chicago, IL | (312) 555-7890 | [email protected] | LinkedIn: linkedin.com/in/janecollinsrn

Professional Summary

Experienced Utilization Review Nurse with over 7 years in clinical case management and utilization review within large healthcare organizations. Certified Case Manager (CCM) with a strong background in evaluating medical necessity, coordinating care, and optimizing resource utilization. Proven ability to collaborate with interdisciplinary teams to ensure compliance with regulatory guidelines and improve patient outcomes. Detail-oriented and adept at data analysis, with a commitment to maintaining the highest standards of patient advocacy.

Core Competencies

1. Utilization Review & Case Management
2. Medical Record Analysis
3. Regulatory Compliance (JCAHO, CMS, NCQA)
4. Interdisciplinary Communication
5. Clinical Documentation Improvement
6. Quality Assurance & Risk Management
7. Insurance Authorization Processes
8. Patient Advocacy & Education

Professional Experience

Northwestern Memorial Hospital, Chicago, IL
Utilization Review Nurse
June 2019 – Present

– Conduct comprehensive reviews of inpatient and outpatient medical records to determine appropriateness of care, ensuring compliance with Medicare, Medicaid, and private insurer policies.
– Collaborate with physicians, case managers, and payers to facilitate timely authorizations and discharge planning, reducing length of stay by 12% over two years.
– Develop and implement utilization review protocols aligned with NCQA and JCAHO standards, enhancing audit readiness and reducing denials by 15%.
– Train nursing staff and case managers on utilization review best practices and documentation requirements, improving interdisciplinary communication.
– Utilize electronic health record (EHR) systems including Epic and Cerner to document findings and track utilization metrics.

Kaiser Permanente, Los Angeles, CA
Case Management Nurse / Utilization Review
August 2015 – May 2019

– Evaluated clinical necessity and appropriateness of services for a patient population exceeding 300 monthly cases, focusing on chronic disease management and post-acute care transitions.
– Coordinated with multidisciplinary teams to develop individualized care plans that balanced patient needs with cost-effective care delivery.
– Monitored compliance with state and federal regulations, reducing readmission rates by 10% through proactive discharge planning and patient education.
– Participated in quality improvement initiatives targeting reduction of unnecessary hospital admissions and lengths of stay.
– Maintained up-to-date knowledge of insurance policies, Medicare guidelines, and clinical best practices to facilitate accurate utilization decisions.

Education

University of Illinois at Chicago
Bachelor of Science in Nursing (BSN)
Graduated: May 2015

Certifications

Certified Case Manager (CCM) – Commission for Case Manager Certification, 2017
Registered Nurse (RN) – Illinois State Board of Nursing
Basic Life Support (BLS) – American Heart Association

Professional Affiliations

American Case Management Association (ACMA)
American Nurses Association (ANA)

Technical Skills

– Electronic Health Records (Epic, Cerner)
– Utilization Review Software (MedeAnalytics, InterQual)
– Microsoft Office Suite (Word, Excel, PowerPoint)

Additional Information

Fluent in Spanish, enabling effective communication with diverse patient populations. Known for maintaining a balanced approach that respects both clinical integrity and organizational cost management goals.

This sample resume demonstrates a balance of clinical expertise, regulatory knowledge, and collaborative skills essential for a Utilization Review Nurse. The content is tailored to highlight measurable accomplishments and certifications that enhance professional credibility.

Utilization Review Nurse Resume Examples

Below is a professionally crafted resume example for a Utilization Review Nurse. This sample demonstrates how to present relevant qualifications, experience, and education clearly and concisely, while maintaining a formal tone and engaging style.

Jane M. Anderson, RN, BSN, CCM

123 Elm Street | Chicago, IL 60616 | (312) 555-7890 | [email protected] | LinkedIn: linkedin.com/in/janeandersonrn

Professional Summary

Experienced and certified Utilization Review Nurse with over seven years in healthcare utilization management and case coordination. Adept at conducting thorough clinical reviews to ensure appropriate care delivery and cost-effective resource utilization. Proven ability to collaborate with multidisciplinary teams to improve patient outcomes and comply with regulatory standards. Certified Case Manager (CCM) since 2018, with a strong background in acute care nursing and managed care environments.

Core Competencies

1. Utilization Management & Review
2. Case Management Coordination
3. Clinical Documentation & Compliance
4. Insurance Authorization & Appeals
5. Quality Improvement Initiatives
6. Patient Advocacy
7. Electronic Medical Record (EMR) Proficiency
8. Regulatory Standards (JCAHO, CMS)

Professional Experience

Senior Utilization Review Nurse
Northwestern Memorial HealthCare, Chicago, IL
June 2019 – Present

– Perform comprehensive utilization reviews for inpatient and outpatient services, ensuring adherence to clinical guidelines and payer policies.
– Collaborate with physicians, nurses, and insurance representatives to facilitate timely authorizations and appeals, reducing denials by 15%.
– Lead quality assurance audits to monitor compliance with Joint Commission standards, resulting in a 10% improvement in documentation accuracy.
– Mentor new utilization review nurses, fostering professional development and knowledge sharing.
– Utilize advanced EMR systems to document findings and communicate care plans effectively.

Utilization Review Nurse
Kaiser Permanente, Oakland, CA
August 2015 – May 2019

– Conducted daily reviews of medical records to determine medical necessity for ongoing treatments and hospital stays.
– Coordinated with case managers and physicians to develop discharge plans that optimized patient care and minimized readmission rates.
– Managed appeals for denied claims, achieving a 20% success rate in overturning initial denials.
– Participated in cross-functional committees aimed at improving patient utilization and cost containment strategies.

Education

Bachelor of Science in Nursing (BSN)
University of Illinois at Chicago – College of Nursing, Chicago, IL
Graduated May 2014

Certifications

Certified Case Manager (CCM)
Commission for Case Manager Certification, 2018 – Present

Registered Nurse (RN) License
Illinois Department of Financial and Professional Regulation, Active

Professional Affiliations

American Case Management Association (ACMA)
Member since 2017

Technical Skills

– Epic and Cerner EMR Systems
– Microsoft Office Suite (Word, Excel, PowerPoint)
– Utilization Review Software (MedeAnalytics, InterQual)

References

Available upon request.

Jane M. Anderson’s resume exemplifies a balanced presentation of clinical expertise, certifications, and professional experience tailored to the utilization review nursing role. It highlights measurable achievements and relevant competencies, making it a strong template for professionals seeking advancement in this specialized nursing field.2025.07.25