Medical Review Nurse Resume

Carrie Johnson

3111 Pine Garden Lane

Atlanta, GA 30339

(555)-555-5555

[email]

Job Objective To obtain a responsible position as a Medical Review Nurse where my past work experience will be helpful.

Summary of Qualifications:

• Remarkable experience in acute care case management and medical and utilization review
• Sound knowledge of HIPAA Privacy and Security Rules and CMS security requirements
• Solid understanding of coding principles to include ICD-9, CPT, HCPCS, DRG and RBRVS
• Huge knowledge of billing forms, RA’s, EOB’s and provider billing statements
• Strong organizational and documentation skills
• Excellent Customer Service Orientation
• Strong Interpersonal Skills
• Outstanding ability to maintain high quality work while meeting strict deadlines

Work Experience:

Medical Review Nurse, August 2005 – Present

HMS, Atlanta, GA

• Performed pre-certification, concurrent and retrospective review of out-patient and in-patient services.
• Consulted complex cases that did not met established criteria and guidelines with the physician advisor.
• Communicated with hospital staff to ensure timely discharge planning and placement in most appropriate setting.
• Evaluated requests for outpatient services such as home care, therapies and DME.
• Identified high-risk members and initiated appropriate referrals to case management, COB/TPL staff, HCCT, etc.
• Adhered to NHPRI benefit plans and ensured members health care needs are fulfilled.

Medical Review Nurse, May 2000 – July 2005

Coventry Health Care, Atlanta, GA

• Completed medical review form, documented findings, and provided policy and regulatory support for determination.
• Conducted research on relevant State specific billing and reimbursement regulations.
• Assisted in resolving Medicaid related issues.
• Participated in on-site visits to retrieve medical records and conducted provider entrance and exit conference.
• Adhered to department and regulatory standards for accuracy, proficiency and documentation.
• Participated in department continuous quality improvement activities.

Education

Bachelor of Science in Allied Health Science, Centre College, Danville, KY

Example #2

Objective Looking for a challenging role as a Medical Review Nurse in the field of the nursing and caring where my skills and knowledge can be utilized effectively.

Career Profile:

• Sound knowledge of the medical terminology, assessments, patient’s evaluation and clinical medicine.
• Strong knowledge of medical terminology and surgical terminology.
• Wide knowledge of the Medicare program.
• Comprehensive knowledge of medical billing and insurance claim filing.
• Broad clinical experience and excellent analytical skills.

Nursing Experience:

Medical Review Nurse, 2004 to till date

Ohio State University Hospital, Columbus, OH

• Performed clinical review of medical records.
• Checked out balances due from insurance companies and sent invoices to insurance companies.
• Entered data electronically to process payments, charges, denials and adjustments.
• Conducted client interviews.
• Maintained internal quality control procedures to ensure the reliability of project reviews.

Academic Background

CPR Certification, 2004

Rush University, Chicago, IL

B.S in Nursing, 2003

Yale School of Nursing, New Haven, CT