Utilization Review/Utilization Management Nurse
Resume:
Javerlie Dela Cruz
********.********@*****.***
SUMMARY OF QUALIFICATIONS
Experienced Utilization Review Nurse boasting 13+ years in healthcare insurance. Eager to contribute to a forward- thinking company valuing precision and superior clinical review expertise. Driven professional hungry for fresh challenges. Demonstrates robust work ethic, resilience, and commendable communication abilities. Proficient in independent work and rapid skill acquisition.
EXPERIENCE
Utilization Management Nurse - Contractor
Gallagher Bassett (Franklin, TN) Jan 23 – June 23
Ensures accurate data entry and timely communication with relevant staff.
Documents review outcomes and liaises with providers and members within set timeframes.
Collaborates with physicians to ensure seamless service provision across the health care continuum.
Escalates non-compliant cases to the Medical Director and quality issues to the Senior Director of Medical Management.
Conducts utilization reviews for outpatient procedures and ancillary services, ensuring medical necessity using clinical review criteria such as CA Medical Treatment Utilization Schedule (MTUS), Official Disability Guideline
(ODG).
Subject Matter Expert- Contractor
Liberty Mutual (Middleton, WI) Dec 2019 – Dec 2022
Performs Workers Compensation Utilization Management Nurse Reviewer duties as required.
Guides WCUM Nurse Reviewers on client and regulatory protocols.
Keeps WCUM Staff updated on regulatory changes and client protocols.
Addresses preliminary review concerns before escalating to the Team Lead.
Daily reports to WCUM leadership on review statistics, issues, and feedback.
Offers performance feedback to Team Lead and Supervisor for staff appraisals.
Oversees WCUM Staff compliance with federal, state, Utilization Review Accreditation Commission (URAC), and client protocols.
Monitors WCUM Nurse Reviewers' case timelines, emphasizing timely completion of priority reviews.
Oversees new hires and provides ongoing coaching with assistance from the WCUM Nurse Team Lead. Telehealth Nurse
Telemedicine Corporation (Hallandale Beach, FL) Jun 2019 – Nov 2019
Handles inbound calls, verifying patient's basic and pharmaceutical information of the patient Genetics, Non-Genetics, Radiation Review Nurse- Contractor Genome (San Francisco, CA) Jun 2017 – May 2019
Conducts post-service claims utilization reviews for medical necessity.
Collaborates with US-based providers and service representatives on clinical decisions for post-service review. Utilization Review Nurse- Contractor
Corvel Corporation (San Antonio, TX) Jan 2013 – April 2017
Examines service requests against clinical review criteria such as CA MTUS, ODG and Milliman, escalating non- compliant cases to physician reviewers.
Ensures timely handling of cases and urgent requests, adhering to URAC, jurisdictional, and best-practice WCUM timeframes.
Reviews claims for medical necessity and coordinates with US-based providers for medical records required for clinical review.
Contributes to the development and rollout of utilization review programs in collaboration with the management team.
Communicates with claims adjusters and providers regarding verifications and releases UR determinations in line with client protocols.
Acts as primary contact for customer complaints and addresses inbound UR-related calls in accordance with client protocols and program strategies.
Maintains required documentation within UR software and upholds Health Insurance Portability and Accountability Act (HIPAA) confidentiality standards.
EDUCATION
Bachelor Of Science in Nursing 2005 – 2010
De Los Santos Medical Center
CERTIFICATION AND LICENSES
Registered Nurse in the State of Texas. License Number 1011294 EXP 2023
NCLEX-RN Passer, State of Oregon. License Number 201340796RN Exp 2019
BLS Number 235********* Exp 2025
ADDITIONAL SKILLS
Advanced with MS Office. Technical savvy and ability to navigate multiple systems and screens while working cases.
Workers Compensation Utilization Review and Utilization Management
Accurate documentation and decision-making
Knowledgeable in ICD-9/10, CPT codes, medical and pharmacological terminologies
Strong clinical knowledge and judgment of medical necessity using clinical review criteria such as CA Medical Treatment Utilization Schedule (MTUS), Official Disability Guideline (ODG).
HIPAA Compliance Training
Adheres to Utilization Review Accreditation Commission (URAC) ACHIEVEMENTS
QA and Prod Stars 2023
Champion Trainer and SME 2021 and 2022
Aud
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