CYNET_SYSTEMS_MAIN_LOGO.gif   Case Management
Utilization Review Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided to IMCS Group on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

  
       
Rating Stars (Click) SETTING 1 2 3 4  
Acute Care   
Skilled/LTAC   
MDS Coordinator   
Home Health   
Telephonic   
Workers Compensation   
Insurance   
Managed Care   
Acute Rehab  
Rating Stars (Click) CM/UR SOFTWARE 1 2 3 4  
Interqual   
Milliman   
MIDAS   
Allscripts UR   
Word Processing Software   
Other: Specify   
Other: Specify  
Rating Stars (Click) REGULATORY 1 2 3 4  
CMS/Medicare   
HEDIS Measures   
Core Measures   
Medicaid/Medical   
DRG   
ICD 9 Coding   
ICD 10 Coding   
CPT  
Rating Stars (Click) PROCESSES 1 2 3 4  
Benefits Eligibility   
Pre-Certification Review   
Review for Admission Criteria   
Identify Appropriate Level of Care   
Review Status During Stay   
Discharge Planning   
Physician Advisor   
Clinical Documentation Improvement   
Needs Assessment/Order DME   
Needs Assessment/Home Health   
Needs Assessment/Hospice   
Needs Assessment/Skilled   
Third Party Authorization Process   
Concurrent Review   
Retrospective Review  
Rating Stars (Click) PROFESSIONAL KNOWLEDGE AND SKILLS 1 2 3 4  
National Patient Safety Goals   
Age Specific/Population Based Care  
Rating Stars (Click) EMR 1 2 3 4  
Epic  
Cerner  
Eclipsys  
McKesson  
Meditech  
Other Computerized System  
Computerized Physician Order Entry  
Bar Coding for Medication Administration  
MY EXPERIENCE IS PRIMARILY IN:  
Unit No. of Years Unit No. of Years  
BURN POST PARTUM  
CRITICAL UNIT LABOR & DELIVERY  
PACU NEWBORN NURSERY  
NEUROLOGY LEVEL II NICU  
TELEMETRY LEVEL III NICU  
MEDICAL PICU  
SURGICAL  PEDIATRICS  
ONCOLOGY OB/GYN  
ORTHOPEDICS PSYCHIATRY  
OPERATING ROOM RRT  
EMERGENCY ROOM CRT  
TRAUMA CENTER LEVEL 1    
COMMUNITY ER    
RURAL ER    
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Newborn/Neonatal (birth – 30 days)  
Infant (30 days-1 year)  
Toddler (1-3 years)  
Preschool (3-5 years)  
School Age Children (5-12 years)  
Adolescent (12-17 years)  
Young Adults (18-44 years)  
Middle Adults (45-64 years)  
Older Adults (>65 years)