Utilization Review Registered Nurse
Resume:
Olga V. Garcia
Pembroke Pines, FL 954-***-**** *********@*****.***
PROFESSIONAL SUMMARY
Experienced Registered Nurse with over a decade of expertise in utilization review, case management, and post-acute care coordination. Proven track record in team leadership, collaboration with multidisciplinary teams, and ensuring optimal patient outcomes. Skilled in electronic medical records
(EMR) systems and training development.
WORK EXPERIENCE
Post Acute Team Lead January 2015 – April 2018
Humana – Work at Home, Miramar, FL
● Directed a utilization review team of 10 RNs and 4 support associates, improving care coordination efficiency.
● Facilitated weekly strategy calls with team members and medical directors to streamline approval processes for skilled nursing, acute rehab, and inpatient rehab facilities.
● Executed performance evaluations, conducted audits, and performed onsite visits to ensure operational excellence.
● Delivered detailed reports and recommendations directly to medical directors and department managers.
Registered Nurse Liaison November 2011 – January 2015 Humana – Work at Home, Miramar, FL
● Reviewed and processed 100+ acute and post-acute Medicare cases monthly, ensuring alignment with medical necessity criteria.
● Collaborated with care teams to develop discharge plans and coordinated transitions to post-acute facilities.
● Presented complex cases to medical directors for approval, managing continued stay criteria and overseeing appeals.
Registered Nurse Case Manager November 2005 – January 2008 Humana – Work at Home, Miramar, FL
● Managed care for Medicare members during acute and post-acute stays, ensuring seamless transitions and compliance with Medicare policies.
● Presented detailed case reports weekly to medical directors for post-acute care plans.
● Delivered discharge planning and utilization review services to out-of-area members, maintaining continuity of care.
EDUCATION
Associate’s Degree in Nursing
Miami-Dade Community College
CERTIFICATIONS & LICENSES
● RN License
SKILLS
● Utilization Review (10+ years)
● Case Management
● EMR Systems (Epic)
● Nursing Experience
● Hospital Experience
● Training & Development (10+ years)
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