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Click here or scroll down to respond to this candidateCandidate's Name
BSN, RNREGISTERED NURSEDallas, TexasPHONE NUMBER AVAILABLEEMAIL AVAILABLEPROFESSIONAL SUMMARYTo assign utilization review requests, verify and enter data in appropriate system, and to provide general support to clinical staff in a team environmentCompassionate and detail oriented Utilization Review Nurse with 8+ years of Utilization Management, Case Management, and Clinical Appeal experience at American multinational managed healthcare and insurance companies, and 2+ years of excellent bedside/clinical nursing care experience as a Medical-Surgical RN, and Progressive Care RN. Knowledge of ICD9, ICD10, and CPT coding and healthcare systems including EPIC, Allscripts, Cerner, MIDAS, and Meditech with excellence in PC literacy, including Microsoft Office products. Experience in using various evidence-based healthcare guidelines such as CaMTUS, ACOEM, ODG, InterQual, and MCG. Very good interpersonal, analytical, interpretive, and organizational skills. Strict compliance with healthcares gold standard accreditation URAC.Accesses, triages, and assigns cases for utilization review. Responds to telephone inquiries proving accurate information and triage as necessary. Enters demographics and utilization review information into claims or clinical management system; maintain data integrity. Obtains all necessary information required for utilization review processing from internal and external sources per policies and procedures. Distributes incoming and outgoing correspondence, faxes and mail; uploads review documents into paperless system as necessary. Supports other units as needed.Available to work anytime as a Full-time Clinical Nurse Reviewer in Utilization Review / Prior Authorization / Medical Necessity Review / Workers Compensation departmentWORK EXPERIENCE UR / UM / APPEALCLINICAL APPEAL CLINICIANConifer Health Solutions; Philippines; July 2021 April 2022Performs retrospective (post-discharge/ post-service) medical necessity reviews to determine appellate potential of clinical disputes/denials or those eligible for clinical review.Constructs and documents a succinct and fact based clinical case to support appeal utilizing appropriate module of InterQual criteria (Acute, Procedures, etc). If clinical review does not meet IQ criteria, other pertinent clinical facts are utilized to support the appeal. Pertinent clinical facts include, but are not limited to, documentation preventing a safe transfer/discharge or documentation of medical necessary services denied for no authorization.Demonstrates ability to critically think, problem solve and make independent decisions supporting the clinical appellate process.Demonstrates proficiency in use of medical necessity criteria sets, MCG and InterQual, as evidenced by Inter-rater reliability studies and other QA audits.WORK EXPERIENCE UR / UM / APPEAL (CONTINUED)CLINICAL SERVICE SPECIALIST CASE MANAGEMENTConifer Health Solutions; Philippines; April 2020 July 2021Ensure proper triaging of patients for observation, or inpatient care.Review patients medical history and records to determine most suitable care plan.Ensure that patients are assigned to the highest possible care from acute, intermediate to critical level depending on the patients medical needs.Ensure to make a sound and accurate determination on time to avoid delays in patient care.Handle wide variety of medical-surgical cases with the use of an evidence-based clinical decision support solution InterQual Criteria.UTILIZATION REVIEW NURSE TEAM LEADERShearwater Health; Philippines; November 2018 February 2020Perform regular quality assessments through live service observations and case reviewsTrain, mentor, and monitor utilization review nurses in the application of evidence-based criteria and jurisdictional guidelines to form utilization, pharmacy review determinationsAssist utilization review nurse staff in communication with patients, providers, claims examinersGuide utilization review nurses through problem solving and appropriate use of evidence-based guidelines such as CAMTUS, ACOEM, and ODGProvide ongoing team training on new utilization and pharmacy review procedures, guidelines, and best practicesPerform regular data gathering, entry, and management within quality monitoring management system to track and document performanceAssist in the management of day to day operations and overall success of the on-site, UR programDetermine the medical necessity of prescribed/recommended treatment requests in order to maximize quality care, provide timely cost-effective outcomes, avoid overutilization of claims, and prevent fraudulent transactionsUTILIZATION REVIEW NURSE SUBJECT MATTER EXPERTShearwater Health; Philippines; August 2017 November 2018Provide real-time assistance to the utilization review nurses when working and completing casesPerform regular and random audits to ensure quality processes are being carried out and ensured that all priority cases were completed in a timely mannerProvide guidance and coaching to others and participated in orientation of newly hired utilization review staffParticipate in ongoing training programs to ensure continued quality performance and compliance with guidelines as a team and as an individualMonitor staff performance based on standards and metricsServe as a liaison between the US account client and the rest of the utilization review teamAct as an individual contributor, performing utilization review:oSought out, obtained and thoroughly reviewed medical records and data from: patients, doctors offices, resolutions managers, adjusters, case managers, facility and/or vendorWORK EXPERIENCE UR / UM / APPEAL (CONTINUED)UTILIZATION REVIEW NURSEShearwater Health; Philippines; February 2014- August 2017Perform timely, evidence -based utilization review services to maximize quality care and cost-effective outcomesIdentify treatment plan requests by obtaining and analyzing medical records that supported the requestsConduct outbound calls, received inbound calls, corresponded via email/snail mail with patients, doctors offices, resolutions managers, adjusters, case managers, facility and/or vendorHandle 20+ cases per day pertaining but not limited to: orthopedic cases related to work injury, medications, durable medical equipment, therapies (PT/OT, acupuncture, chiropractic), injections, imaging procedures (X-ray, MRI, CT, Ultrasound) and diagnostic/therapeutic surgeriesWORK EXPERIENCE BEDSIDE RNSTAFF REGISTERED NURSE PROGRESSIVE CARE UNITPresbyterian Santa Fe Medical Center; New Mexico; June 2023 PresentCoordinate and implement patient care specific to the age of the patient.Change dressings, insert catheters, and start IVsAdjust specialized medical equipment as needed, as well as interpret and record measurementsMonitor patients vitals and report adverse reactions to medications in a timely mannerCollaborate on discharge planning with the healthcare teamAnswer questions and educate patients and their families on surgical procedures and post-surgery careMaintain and update patient files, medical charts, and health recordsAdhere to best nursing practices, standards, and protocolsSTAFF REGISTERED NURSE MEDICAL / SURGICAL UNITChristus St. Vincent Regional Medical Center; New Mexico; September 2022 June 2023Safely and independently administers prescribed treatments, medications, and nursing interventions based on assessment and plan of care.Appropriately organizes and prioritizes time based on patient condition and expected workloadIdentifies changes in patients' status and acts accordingly.STAFF REGISTERED NURSE MEDICAL / SURGICAL UNITManila Doctors Hospital; Philippines; October 2021 July 2022Provide nursing care to patients with acute/chronic medical illnesses.Advocate needs of, and assists patients and significant others in receiving proper medical care during hospitalization.Coordinate flow from ED, OR/PACU, PCU, CCU, or direct admit patients from home or Physician's office.Deal with patient and physician complaints.Coordinate patient care assignments, maintained drug accountability, ensured proper documentation and equipment maintenance.WORK EXPERIENCE - OTHERSTECHNICAL SUPPORT REPRESENTATIVEStream; Philippines; July 2013 November 2013Resolve technical issues of a wide range of complexity by guiding the customers through step-by-step process over the phone and via computer remote accessProvide excellent customer support and customer service while troubleshooting these technical issuesPerforme soft selling to the brand users in USADATA ANALYSTPointwest Corporation; Philippines; July 2012 April 2013Source, sort, and prepare data for computer entryProcess client source documents by reviewing data for deficienciesExamine documents and data for incorrect information and formatting to maintain quality controlEDUCATIONBACHELOR OF SCIENCE IN NURSINGFar Eastern University Dr. Nicanor Reyes Medical FoundationGraduated School Year 2012LICENSURE & CERTIFICATIONSRN Registered Nurse License Number 68805New Mexico Compact status: Multistate (Expiration: 12/31/2025)Authorized to practice in 40 states including TexasACLS Advanced Cardiac Life SupportAugust 2024BLS Basic Life SupportAugust 2024Baylor family medical center rockwall1975 alfa drive inpatient tele 7pm-7am60 972/wk 2160 gross 972/wk |
