Utilization Review Registered Nurse

JEANNE RODEN

***** ********** *** **** ********, MN 56444 763-***-**** **********@***.***

SUMMARY

Knowledgeable Utilization Review Nurse with approximately 17 years of experience as a Registered Nurse with Utilization Review experience. I have worked for a Quality Improvement Organization (QIO) serving Medicare recipients where I authorized services. I applied evidence-based decision-making, critically evaluating patient-care practices. My skills of providing leadership, training, and oversight in utilization review, risk management, and quality assurance received high marks. Being able to deliver high quality and appropriate patient services of upmost priority.

EXPERIENCE

Skilled Nursing Care

Crosby Care Center

Crosby MN 56444

Responsibilities: Feb 2024 to present

Skilled nursing care unit. Team leads for 14 bed unit. Daily medications, treatments, IV therapy, tube feedings. Maintenance rehab services. Provide supervision for direct care givers.

Utilization Review Nurse (URN)

Keystone Peer Review Organization, Inc. (KEPRO) / Remote – Harrisburg, PA

Responsibilities: Aug 2015-April 2021

Critically examined patient medical records to the appropriateness of healthcare received. Used review criteria to create an accurate account of the patient’s clinical picture. Played an important role in the authorization process while creating contacts with insurance companies, healthcare providers, and patients. Provided quality and effective documentation of patient’s condition, change from baseline, treatments required, positive and negative responses to treatment, diagnostic abnormalities, and the patient’s progression.

Skills:

Knowledgeable of HIPPA. Used the following documentation standards: Milliman Care Guidelines (MCG), Centers for Medicare (CMS), Clinical Pharmacology, and contract guidelines. Solid documentation skills with ability to read abnormal clinical findings on physical examinations, vital-sign measurements, laboratory tests, and imaging studies. Collaboration amongst team members involved in patient care. Great communication skills with Medical Doctors when reviews were necessary. Prior authorization review skills for Skilled Nursing Facility (SNF) in-patient stays.

Generalist, Registered Nurse (RN)

Univita Health, Inc. / Remote – Eden Prairie, MN

Responsibilities:Oct 2005 – July 2015

Developed, revised, and implemented Utilization Management (UM) policies and procedures. Managed effective UM processes that resulted in cost efficient of services. Maintained process for delegated UM vendor services. Developed and supported relationships with providers that results in continued improvement in quality healthcare outcomes. Performed all duties in a UM role. Collaborated with peers in Medical Management, Quality Management, and Grievance and Appeals.

Skills:

Strong interpersonal, relationship-building and listening skills, with a consultative style. Ability to energize, communicate, and build rapport at all levels within an organization. Strong project skills, and able to work in a fast-paced environment. Microsoft Office, proficiency. Ability to maintain a high level of integrity and confidentiality of medical information.

EDUCATION

Bachelor of Science in Nursing (BSN)

Liberty University

May 2014

Summary of relevant coursework taken: Fundamentals of Nursing, Pharmacology, Strategies for Mental Health Care, Leadership/Management Nursing, Strategies for Adult Health Care I & II, and Nursing Care.

Associate Degree in Nursing

Anoka-Ramsey June 1985

COMMUNICATION

Maintained excellent communication skills with staff, patients, and third-party vendors in an online environment. Very organized and attention to detail with daily emails and phone communications. Participated in the online Zoom meetings.

LEADERSHIP

Wrote the How-To process on Claims and provided Training on the tool for Claims per the carrier’s guidelines. Presented and trained new Utilization staff. Met high expectations of the Service Level Agreements (SLAs).

REFERENCES

Available Upon Request

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