Utilization Review Registered Nurse
Resume:
Margie Calumarde
BSN, RN
REGISTERED NURSE
Dallas, Texas
ad5qgh@r.postjobfree.com
PROFESSIONAL SUMMARY
To assign utilization review requests, verify and enter data in appropriate system, and to provide general support to clinical staff in a team environment
Compassionate 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 healthcare’s 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 / Worker’s Compensation department
WORK EXPERIENCE – UR / UM / APPEAL
CLINICAL APPEAL CLINICIAN
Conifer Health Solutions; Philippines; July 2021 – April 2022
Performs 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 MANAGEMENT
Conifer Health Solutions; Philippines; April 2020 – July 2021
•Ensure 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 LEADER
Shearwater Health; Philippines; November 2018 – February 2020
Perform regular quality assessments through live service observations and case reviews
Train, mentor, and monitor utilization review nurses in the application of evidence-based criteria and jurisdictional guidelines to form utilization, pharmacy review determinations
Assist utilization review nurse staff in communication with patients, providers, claims examiners
Guide utilization review nurses through problem solving and appropriate use of evidence-based guidelines such as CAMTUS, ACOEM, and ODG
Provide ongoing team training on new utilization and pharmacy review procedures, guidelines, and best practices
Perform regular data gathering, entry, and management within quality monitoring management system to track and document performance
Assist in the management of day to day operations and overall success of the on-site, UR program
Determine 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 transactions
UTILIZATION REVIEW NURSE – SUBJECT MATTER EXPERT
Shearwater Health; Philippines; August 2017 – November 2018
Provide real-time assistance to the utilization review nurses when working and completing cases
Perform regular and random audits to ensure quality processes are being carried out and ensured that all priority cases were completed in a timely manner
Provide guidance and coaching to others and participated in orientation of newly hired utilization review staff
Participate in ongoing training programs to ensure continued quality performance and compliance with guidelines as a team and as an individual
Monitor staff performance based on standards and metrics
Serve as a liaison between the US account client and the rest of the utilization review team
Act as an individual contributor, performing utilization review:
oSought out, obtained and thoroughly reviewed medical records and data from: patients, doctor’s offices, resolutions managers, adjusters, case managers, facility and/or vendor
WORK EXPERIENCE – UR / UM / APPEAL (CONTINUED)
UTILIZATION REVIEW NURSE
Shearwater Health; Philippines; February 2014- August 2017
Perform timely, evidence -based utilization review services to maximize quality care and cost-effective outcomes
Identify treatment plan requests by obtaining and analyzing medical records that supported the requests
Conduct outbound calls, received inbound calls, corresponded via email/snail mail with patients, doctor’s offices, resolutions managers, adjusters, case managers, facility and/or vendor
Handle 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 surgeries
WORK EXPERIENCE – BEDSIDE RN
STAFF REGISTERED NURSE – PROGRESSIVE CARE UNIT
Presbyterian Santa Fe Medical Center; New Mexico; June 2023 – Present
Coordinate and implement patient care specific to the age of the patient.
Change dressings, insert catheters, and start IVs
Adjust specialized medical equipment as needed, as well as interpret and record measurements
Monitor patients’ vitals and report adverse reactions to medications in a timely manner
Collaborate on discharge planning with the healthcare team
Answer questions and educate patients and their families on surgical procedures and post-surgery care
Maintain and update patient files, medical charts, and health records
Adhere to best nursing practices, standards, and protocols
STAFF REGISTERED NURSE – MEDICAL / SURGICAL UNIT
Christus St. Vincent Regional Medical Center; New Mexico; September 2022 – June 2023
Safely 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 workload
Identifies changes in patients' status and acts accordingly.
STAFF REGISTERED NURSE – MEDICAL / SURGICAL UNIT
Manila Doctors Hospital; Philippines; October 2021 – July 2022
Provide 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 - OTHERS
TECHNICAL SUPPORT REPRESENTATIVE
Stream; Philippines; July 2013 – November 2013
Resolve technical issues of a wide range of complexity by guiding the customers through step-by-step process over the phone and via computer remote access
Provide excellent customer support and customer service while troubleshooting these technical issues
Performe soft selling to the brand users in USA
DATA ANALYST
Pointwest Corporation; Philippines; July 2012 – April 2013
Source, sort, and prepare data for computer entry
Process client source documents by reviewing data for deficiencies
Examine documents and data for incorrect information and formatting to maintain quality control
EDUCATION
BACHELOR OF SCIENCE IN NURSING
Far Eastern University – Dr. Nicanor Reyes Medical Foundation
Graduated School Year 2012
LICENSURE & CERTIFICATIONS
RN Registered Nurse – License Number 68805
New Mexico – Compact status: Multistate (Expiration: 12/31/2025)
Authorized to practice in 40 states including Texas
ACLS Advanced Cardiac Life Support
August 2024
BLS Basic Life Support
August 2024
Baylor family medical center rockwall
1975 alfa drive inpatient tele 7pm-7am
60 972/wk 2160 gross 972/wk
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