Utilization Review Registered Nurse Resume Eva Sanders Utilization Review Registered Nurse 816-555-0147 eva.sanders@email.com linkedin.com/example/evasanders Kansas City, MO 64111 STRENGTHS Clinical assessment Review acuity, treatment response, and resource needs together, helping clarify the clinical picture behind inpatient decisions. Clear case communication Medical directors receive concise clinical summaries, and providers get specific explanations when records need clarification. Transition planning Coordinate referrals and discharge details with care management, keeping post-acute needs visible during inpatient review. Policy-aligned records Document rationales, actions, and discharge plans in health systems so review decisions remain easy to follow. Bedside perspective Acute care experience informs review of changing patient needs; interdisciplinary partners have a practical clinical context. SKILLS Concurrent review Acute care nursing Utilization management Medical necessity review Level-of-care assessment Clinical judgment Discharge planning Medicare and Medicaid Clinical documentation Provider education Care coordination Post-acute transitions Clinical case review Transfer planning Continuity of care LANGUAGES English Native 40 Spanish Beginner 10 MY CAREER 3.9 Years Utilization Review Registered Nurse at SummitPath Health Services (1.4 Years) Medical-Surgical Registered Nurse at Riverbend Regional Medical Center (2.5 Years) SUMMARY Missouri-licensed Registered Nurse with four years of experience in acute inpatient care and health plan utilization review . Assess inpatient acuity, treatment progress, resource use, length of stay, medical necessity, and discharge readiness to inform clinically appropriate reviews. Coordinate with providers, medical directors, and care management teams to clarify records and support transitions across care settings. Bring more than two years of acute care practice and a Bachelor of Science in Nursing to concurrent review, with working knowledge of Medicare and Medicaid requirements. Document findings in health management systems, explain review processes to providers, and share practical feedback on care gaps and review workflows. Apply bedside assessment and utilization management judgment to support continuity, appropriate access to services, and patient-centered discharge planning. EXPERIENCE Utilization Review Registered Nurse SummitPath Health Services May 2025 - Present Kansas City, MO Coordinate concurrent inpatient reviews with providers, medical directors, and care management teams, applying clinical judgment to member acuity, treatment needs, and appropriate levels of care. Clarify documentation and review findings to inform medical determinations, then record rationales and discharge plans in health management systems. Share recurring care-setting concerns with clinical leaders to inform policy discussions and practical review adjustments. Reviewed acute inpatient cases against medical necessity criteria , assessing acuity, resource use, response, and length of stay. Presented clinical summaries to medical directors, resolving documentation questions before service determinations were finalized. Guided provider offices through utilization review requirements, clarifying record gaps and supporting timely recommendations. Entered review rationales, actions, and discharge plans in health management systems under utilization policies. Coordinated care management referrals and transition barriers, supporting timely movement between inpatient and post-acute settings . Shared recurring care-setting concerns with clinical leaders, informing policy discussions and review workflow adjustments. Medical-Surgical Registered Nurse Riverbend Regional Medical Center Oct 2022 - Apr 2025 Independence, MO Provide medical-surgical inpatient nursing for adults with varied treatment needs, drawing on bedside assessment to recognize changing acuity and support timely escalation. Coordinate with physicians, case managers, patients, and families around care milestones, handoffs, and discharge readiness. Through that clinical perspective, contribute to interdisciplinary discussions of utilization and barriers to appropriate inpatient care. Provided bedside nursing for medical-surgical inpatients, coordinating daily care as acuity and treatment needs changed. Reviewed vital trends, diagnostics, and treatment response to flag deterioration and support timely escalation. Partnered with physicians and case managers to align care milestones with realistic discharge readiness. Documented assessments, interventions, and handoffs in electronic records, strengthening continuity across rotating care teams. Prepared patients and families for transitions, clarifying medication plans, follow-up needs, and warning signs. Contributed utilization details during interdisciplinary rounds, helping resolve barriers to medically appropriate inpatient care. PROJECTS Concurrent Inpatient Review Practice 2026 Apply inpatient clinical review experience to assess acuity, treatment progress, resource use, and discharge readiness; coordinate review information with care management and providers to support continuity across inpatient and post-acute settings. LEADERSHIP & AWARDS Clinical Review Contribution, recognized for clear case summaries and policy-aligned documentation in utilization review. Patient Transition Coordination, acknowledged for supporting interdisciplinary discharge planning and continuity of care. EDUCATION Bachelor of Science in Nursing University of Missouri-Kansas City GPA: 3.8 2022 Kansas City, MO Coursework: Medical-surgical nursing, pharmacology, pathophysiology, nursing research CERTIFICATIONS Registered Nurse, Missouri 2026 Basic Life Support (BLS) 2026 TECHNICAL SKILLS Electronic Health Records: Epic, Oracle Health, MEDITECH Health Plan Systems: HealthEdge GuidingCare, InterQual, MCG Clinical Reference Tools: UpToDate, DynaMed, Lexicomp Office Software: Microsoft Word, Microsoft Excel, Microsoft Outlook Video Conferencing: Microsoft Teams, Zoom, Cisco Webex Clinical Coding: ICD-10-CM, CPT, HCPCS Interoperability Standards: HL7, FHIR, CDA Operating Systems: Windows, macOS, iOS Documentation Formats: PDF, DOCX, XLSX Data Exchange: SFTP, HTTPS, XML SKILLS Concurrent review Acute care nursing Utilization management Medical necessity review Level-of-care assessment Clinical judgment Discharge planning Medicare and Medicaid Clinical documentation Provider education Care coordination Post-acute transitions Clinical case review Transfer planning Continuity of care PROFESSIONAL AFFILIATIONS Member, American Nurses Association, professional nursing association. Member, American Case Management Association, professional community focused on care coordination. LANGUAGES English (Native) Spanish (Beginner) ADDITIONAL INFORMATION Work Status : Authorized to work in United States. No sponsorship required. ADDITIONAL INFORMATION Work Status : Authorized to work in United States. No sponsorship required. REFERENCES AVAILABLE ON REQUEST
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