Utilization Review Specialist Resume Guide

Passionate utilization review specialist with 8+ years of experience in healthcare quality management. Skilled at making quick decisions to ensure that care is appropriate, medically necessary and cost-effective for a variety of insurance payers such as Medicare, Medicaid and private insurers. Experienced in analyzing patient medical records for coding accuracy and compliance with regulatory guidelines. At XYZ Medical Center, reduced the number of denied claims by 30%.

Well-rounded utilization review specialist with 8+ years of experience in healthcare. Skilled at performing medical necessity reviews, coordinating pre-certification and concurrent utilization activities for large insurance companies. Proven track record of reducing costs by 10% while ensuring quality care delivery to patients. Experienced in developing effective strategies to improve operational efficiency without compromising patient safety or satisfaction levels.

Committed utilization review specialist with 8+ years of experience in healthcare and managed care. At XYZ, identified potential opportunities for cost savings while ensuring compliance with all applicable laws and regulations. Demonstrated proficiency in using data to identify trends in utilization and quality of services provided by providers. Skilled at working collaboratively with stakeholders from payers, providers, members, patients’ families and employers.

Diligent Utilization Review Specialist with 5+ years of experience in healthcare and insurance industry. Adept at evaluating patient medical records to ensure cost-effective care, compliant with standards set by government regulations. Proven success in reducing costs for a major managed care organization while maintaining quality of service. Seeking opportunity to apply knowledge and expertise as Utilization Review Specialist at ABC Healthcare Services.

Proficient Utilization Review Specialist with 5+ years of experience in ensuring quality and compliance standards are met. Experienced in providing medical necessity reviews on a variety of services, such as hospitalizations, physician visits, home health care services and durable medical equipment requests. Skilled at working effectively with physicians to ensure timely service delivery while maintaining cost-effective utilization practices.

Determined utilization review specialist with 5+ years of experience in performing utilization reviews and analyzing data to ensure optimal patient care. At XYZ, conducted over 200 concurrent and retrospective authorization requests for the hospital’s mental health services. Recognized by peers as a team-oriented individual who is detail oriented while remaining focused on cost containment strategies that maintain quality of care standards.

Skilled utilization review specialist with 6+ years of experience in reviewing and approving medical care services for insurance companies. Adept at interpreting complex regulations, developing utilization plans, and managing authorization processes. At Company X, reduced turnaround times by 10% while ensuring quality standards were met or exceeded. Seeking to use my expertise to help ABC achieve its objectives.

Driven Utilization Review Specialist with 5+ years of experience in healthcare and managed care. Seeking to join ABC Healthcare as the new Utilization Review Specialist and leverage expertise in pre-authorizations, utilization management, discharge planning, and quality improvement initiatives. At XYZ Inc., reduced denials by 15% via utilizing data analysis tools for monitoring utilization trends.

• Structured utilization review processes for over 20 hospitals, reducing denials by 30% and increasing first-time claim approval rate to 95%.
• Reported utilization trends and issues to stakeholders while recommending changes in order to meet established performance goals; cut overall healthcare costs by $200K within 6 months.
• Improved the accuracy of medical claims through managing data entry personnel and verifying entered information with patient records; reduced errors from 17% to 3%.
• Reconciled discrepancies between billing department/payer information & provider’s clinical documentation as needed, ensuring timely reimbursement collection without any delay.
• Proficiently managed authorizations for services such as radiology, laboratory tests and hospital stays according to insurance plan guidelines; achieved 100% compliance with state regulations governing Utilization Review activities within one year of employment.

• Resolved and processed over 2000 utilization reviews in a timely manner, ensuring that medical treatments and services adhered to insurance company standards while decreasing turnaround time by 25%.
• Documented detailed reports on all completed utilization reviews, outlining reasons for approval or denial; reduced administrative errors by 30% through careful inspection of patient records.
• Optimized the overall process of utilization review with innovative strategies such as designing new forms and creating collaborative workflows between departments; improved efficiency by 40%.
• Compiled comprehensive monthly summaries of all approved/denied cases using data from multiple sources; identified discrepancies in procedures which led to $10,000 savings per quarter throughout the organization.
• Diligently monitored changes in healthcare regulations & guidelines related to utilization review processes to ensure compliance with local laws and increase accuracy rates across the board by 10%.

• Achieved 98% accuracy in reviewing and approving insurance claims, ensuring that all healthcare providers were appropriately reimbursed within 5 days of initial submission.
• Resourcefully identified medical errors or discrepancies on patient records to prevent potential fraud cases; saved the company $30K over 6 months with improved utilization review procedures.
• Facilitated successful communication between patients, health plan members and healthcare facilities regarding billing inquiries & other related issues; reduced customer complaints by 45%.
• Processed 2,500+ authorization requests per month for medical services such as home health care visits, hospitalizations and outpatient treatments following established protocols & guidelines set forth by regulatory bodies like CMS/Medicare Medicaid etc..
• Demonstrated expertise in using different computer programs including MS Office Suite (Excel), Epic EHR software and CPT coding manuals to ensure accurate documentation of patient information & reimbursement processes at all times.

• Audited and processed 500+ patient medical records and utilization reviews per month, ensuring accuracy of billing codes, authorization requests and review outcomes.
• Expedited the implementation of new strategies for managing utilization trends to reduce healthcare costs by 10% in 6 months.
• Coordinated with insurance companies to ensure compliance with coverage requirements; successfully resolved 120+ disputes related to reimbursement claims within a 3-month period.
• Successfully improved turnaround time on account denials from 5 days to 2 days through streamlined processes and effective communication skills across all departments involved in the process chain flow management system (PCFMS).
• Reorganized over 1,000 files containing prior authorizations/denials data into an organized electronic filing system that increased efficiency by 25%.

• Analyzed medical records and claims data to accurately assess the utilization of healthcare services, resulting in a 10% decrease in unnecessary costs.
• Monitored health plan members’ care utilization patterns for any potential misuse or underuse of medical treatments; identified $20,000 worth of fraudulent activities over 3 months.
• Reviewed up to 400 patient files per week on an independent basis with attention to detail and accuracy; reduced turnaround time by 15%.
• Independently managed all aspects of clinical review processes while meeting strict regulatory guidelines & deadlines set by insurers & government agencies such as Medicaid & Medicare programs.
• Researched best practices related to current evidence-based standards regarding chronic condition management, preventive medicine protocols and quality improvement initiatives for optimal outcomes at minimum cost savings annually.

• Confidently evaluated and analyzed medical records of 250+ patients per week to determine the appropriateness, necessity and quality of care provided in accordance with policy guidelines; reduced overall healthcare costs by 10%.
• Introduced best practices for utilization review process into practice that enabled faster data collection & decision making while maintaining accuracy; increased efficiency by 8 hours a day.
• Developed reports on utilization patterns, trends and opportunities for improvement based on audit findings; identified cost savings opportunities totaling $100K in the first year alone.
• Interpreted complex clinical information from multiple sources such as patient charts, lab results & physician notes quickly and accurately to ensure optimal health outcomes without sacrificing safety or quality standards.
• Successfully collaborated with other members of multidisciplinary teams including physicians, nurses & administrators to clarify diagnosis codes or procedures whenever needed during reviews.

• Assessed health care services of over 400 patients per month, ensuring compliance with all regulations and that insurance coverage was maximized.
• Effectively communicated utilization review decisions to medical providers via phone, email and written correspondence; reduced appeals by 30%.
• Spearheaded the development of a new methodology for evaluating patient health needs; increased cost savings by $25K annually.
• Participated in weekly meetings with other professionals to discuss difficult cases and formulate solutions to meet patient needs without compromising quality standards or exceeding budget constraints.
• Represented the organization at regional conferences related to utilization management initiatives, collaborating with industry leaders on best practices for promoting improved outcomes & system efficiencies across healthcare organizations.

Bachelor of Science in Health Administration
Educational Institution XYZ
Nov 2011

Certified Utilization Review Specialist (CURS)
American
May 2017