Resume

Utilization Reviewer Review

Location:

King City, CA

Salary:

$60 per hour

Posted:

February 01, 2024

Contact this candidate

Resume:

Ramos, Imelda B. BSN, USRN

** **. ******* *****, **** 86 Greenfield CA 93927

ad3aq2@r.postjobfree.com

mobile no: 207-***-****

Job Title: Utilization Review Nurse, Senior Analyst,

I am honored to be chosen to work in your Facility. I appreciate the opportunity to make a real difference in patients’ day-to-day lives and I find the profession endlessly interesting and rewarding.

My background includes more than 2 years of hospital bedside experience (medical surgical care), including volunteering in local hospitals in the Philippines, 3 months staff nurse at a Long Term Care Facility here in US, and 8 years of strong experience in health care insurance industry. (Anthem Blue Cross and Aetna, Medicare and Medicaid), BPO Company in the Philippines Accenture Inc. and Cognizant Solutions Philippines. I am currently employed with Nexus based in Texas USA as Utilization Review nurse.

PROFESSIONAL QUALIFICATIONS

Education:

Bachelor of Science in Nursing graduate

Unciano Colleges, Inc.

75 L. Sumulong Memoria Circle

1870 Antipolo City Philippines

Graduated: April 11, 2006

Basic Life Support - American Heart Association, Expires 06/2024

Examinations/Certifications Result/status

National Counsil Licensure Examination (NCLEX) for Registered Nurses : PASSED

Professional Regulation Commission Board of Nursing Philippines: PASSED

Professional License:

State of Licensure: California

License Number: 95344355

Issuance Date: July 14, 2023

Expiration Date: December 31, 2024

State of licensure: New York City

License No.:681876

Status: Valid Until Oct 31, 2025

State of Licensure: Maine (Compact License)

License No.: RN83754

Date Issued: September 29, 2022

Valid until: Nov. 15, 2025

Philippines Board of Nursing

o License Number: 406530

o Valid Until: November 15, 2024

PERSONAL INFORMATION:

• Date of Birth : November 15, 1965

• Gender : Female

• Marital status : Married

Height: 5”6’

Weight: 70 kg.

CLINICAL SKILLS:

Head to toe assessment and wound treatment

Prioritizing work

Administer medications

Administer immunizations

Performed catherization and collected specimens.

Communicating with supervisor and peers

G – Tube feeding and assisted care

Provide and family education

Performed tracheostomy and suctioning and care.

Educated safety for pediatric to geriatric

Software – ECS, MS word, Excel,

EMPLOYMENT HISTORY:

STAFF NURSE

Midcoast Senior Health Care Center (Long Term Care)

(October 3, 2022- January 17, 2023)

58 Baribeau Drive

Brunswick, Maine 04011

Phone:207-***-****

Comprehensive Job Description:

Perform total patient care including personal hygiene, Demonstrates effective communication and collaboration skills when interacting with patients/families and co-workers, maintained all the necessary equipments and proper medical supplies, assist in ADLs and care given to patient’s, administering medications as ordered. Promotes continuity of patient care through oral and written communication.

Recorded all care information concisely, accurately and completely in a timely manner in the appropriate format.

Promoted a therapeutic environment to ensure patients were treated in a professional, ethical and tactful manner.

Utilization Review Nurse (From February 27, 2023 to present)

Nexus

5600 Schertz

Parkway Suite 200

Schertz, Texas 78154

830-***-****

Duties and Responsibilities:

Perform case reviews (pre-authorization) and establishes and maintains efficient methods of ensuring the medical necessity and appropriateness of providers and patients requests for diagnostic, rehabilitation or surgical procedures and certifies reviews that meet clinical review criteria/guidelines.

Manages assigned workload within established performance standards.

Maintains confidentiality of all information, policies, and procedures as required by the Health Insurance Portability and Accountability Act (HIPAA) protocols.

Maintains all required utilization management review documentation in the UM software in a timely manner.

UM Nurse Consultant, Cognizant Technology Solutions, Philippines Inc.

From Aug 23, 2021 up to May 14, 2022

Duties and Responsibilities:

Performs utilization management reviews in accordance with federal and state mandated regulations. Maintains compliance with regulatory changes affecting utilization management.

Process pre-authorization review for insurance claims for Medicare and Medicaid Facility, members and providers.

Certifies reviews that meet clinical review criteria/guidelines.

Maintains acceptable levels of performance including but not limited to attendance, adherence to protocols, customer courtesy, and all other productivity and efficiency targets and objectives.

Learns new methods and services as the job requires.

Advises supervisor of any potential problems as they become evident.

Manages assigned workload within established performance standards.

SR. NURSE CASE ANALYST (Post Service Clinical Care Service)

ACCENTURE, INC, Philippines

July 14, 2014 to Sep, 29, 2020

Job Description :

Perform UM reviews (prospective/concurrent/retrospective) for inpatient/ outpatient services, medications or drugs as specified in the scope of work with different clients according to the URAC standards and client requirements and/or policies.

Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer.

Tracks status of all utilization management reviews in progress

Certifies reviews that meet clinical review criteria/guidelines.

Adheres to quality standards and state UM guidelines.

Reviews UM requests for services against established clinical review criteria, referring cases not meeting criteria to a physician reviewer.

Maintains all required utilization management review documentation in the UM software in a timely manner.

CHARACTER REFERENCES:

Denise Collazo

Nexus

HR Director

830-***-**** to 7020

Stacey Morse: