Registered Nurse Utilization Review
Resume:
MAY ASTER VALDELLON
Registered Nurse, BSN
About Me
Professional Experience
I’m dedicated and driven registered nurse who enjoys providing patient-centered care. I have 11 years of total nursing experience, most of my years spent in utilization review and case management. I’ve always been a naturally caring person and willing to go extra mile to ensure fairness for all patients.
RN Licenses
California RN License
Tennessee RN License (compact)
Texas RN License
Expertise
Utilization Review
Case Management
Medical-Surgical
Skilled Nursing/Long term Care
Education Background
BS in Nursing
Southern Luzon State University
2008-2012
Scarlett Taylor, RN
RN Supervisor - NHC Scott
Valerie Martinez, RN
Utilization Review Nurse - Team Lead
My Contact
***.******@*****.***
22302 Birds Eye Dr.
Diamond Bar, CA 91765
National Healthcare Corporation Charge Nurse
myNexus l Nurse Medical Management II
Blue Cross Blue Shield of Florida / Emblem Health New York UR Nurse/Inpatient Care Management (Concurrent Review) June 2022 - October 2023
October 2021 - March 2022
September 2016 - June 2020
Responsible for maintaining clinical competency as evidenced by application of integrated nursing knowledge and skills, leadership, and communication skills. Utilizes the nursing process in assessment, planning, and implementing care.
Exhibits organizational ability related to workflow, prioritizing to meet the patient care needs
Key responsibilities:
Conducts precertification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts.
Consults with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process.
Key responsibilities:
Assesses the medical necessity, quality of care, level of care and appropriateness of health care services for plan members. Applies clinical review criteria and guidelines in determining the medical necessity of health care services against the clinical data provided.
Certifies cases that meet clinical review criteria and guidelines. Consults with physician when reviews do not meet clinical review criteria and guidelines
Key responsibilities:
CIGNA / Clinical Prior Authorization Nurse
May 2014 - September 2016
Ensure that patients receive the care they need without burdening the healthcare system with unnecessary procedures, and effective treatments or overlong hospital stays through regular reviews and audits
Help insured to make informed decisions about their healthcare by educating them on the benefits and limitations of their health insurance
Pre-certify people for medically necessary procedures and hospitalizations Involves decision making to ensure that healthcare facilities can provide appropriate care Key responsibilities:
References
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