Case Management Utilization Skills Checklist
  Case Management
Utilization Review Skills Checklist
   NAME    
   LAST 4 OF SSN      
   DATE    
I hereby certify that ALL information I have provided 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) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)  
Rating Stars (Click) EMR 1 2 3 4  
Epic   
Cerner   
Eclipsys   
McKesson   
Meditech   
Allscripts   
Other: Specify  
  EMR Conversion
   
CERTIFICATIONS     Expiry Date :   
BLS  
Certified Case Manager (CCM)  
Accredited Case Manager (ACM)  
Certified Disability Management Specialist (CDMS)  
Certified Clinical Documentation Specialist (CDMS)  
ACLS  
  Other: Please note any ICD 10 training   
  Other: Specify