RN Utilization Review Specialist - 20+ yrs UR expertise

Victoria Mallette

Windcrest, TX *****

TX RN License No.: 698283 (Expires: 04/30/2027

Summary:

Registered Nurse with an active compact license in Texas and over 20 years of clinical nursing experience, including 13+ years in Utilization Review across various MCOs and healthcare settings.

Experienced in performing inpatient, outpatient, concurrent, prospective, retrospective, appeals, and claims reviews for members requiring hospitalizations, procedures, and prior authorizations.

Skilled in claims review and processing using Optum360 and conducting pre-certification reviews to determine medical necessity.

Reviewed an average of 20–22 cases daily, including appeals related to denials for lack of medical necessity or inappropriate level of care.

Utilized clinical judgment and evidence-based criteria (MCG, InterQual), CMS guidelines, and UM/CM standards to evaluate the appropriateness of care or escalate for physician review.

Brings a strong work ethic, excellent organizational skill, and advanced critical thinking with proficiency in clinical guidelines and EMR/EHR platforms to ensure accurate and compliant utilization decisions.

Proficient in Microsoft Office, HIPAA compliance, clinical documentation, and regulatory standards including URAC, NCQA, NCCN, and Texas state regulations.

Education:

Pima Community College – Tucson, AZ May 2003

Associate’s Degree in Nursing

Skills:

Utilization Review

Claims Review

MCG, InterQual, CMS criteria

Medical necessity

URAC & NCQA standards

Claims processing system

MCO experience

CM and UM standards

ICD and CPT codes

Certifications and Licenses:

Active Registered Nurse compact license – Texas, License Number: 698283 – expires: Apr 2027 (unrestricted)

Certified Case Manager CCM Number: 4219510- expires April. 2026

Professional Experience:

Community Health Choice – Remote Aug 2023 to Present

RN Utilization Review Nurse

Conduct preservice utilization reviews for the Texas Medicaid STAR Program, focusing on determining the medical necessity and appropriateness of requested services.

Review prior authorization requests for medications (including chemotherapy), inpatient and outpatient procedures, and services for both adult and pediatric populations.

Ensure alignment with established clinical guidelines and state Medicaid requirements, maintaining compliance with regulatory and payer-specific standards.

Collaborate with providers, pharmacists, and interdisciplinary teams to support timely and effective patient care while promoting cost-effective resource utilization.

Utilize clinical judgment and evidence-based criteria to render determinations and contribute to quality patient outcomes through appropriate care planning.

Prospect Medical Systems – Remote May 2023 to Aug 2023

RN Inpatient Case Manager

Performed case management concurrent medical reviews for LOS, participated in daily patient rounds with social workers, therapists and MDs for presentation to the medical director to coordinate plans of care, updating daily census with inpatient admission and discharges, ongoing patient assessments and discharge care planning in conjunction with an interdisciplinary care team.

United Health Group/Optum – Remote Feb 2017 to May 2023

Utilization Review RN

Performed comprehensive utilization reviews for commercial clients, including inpatient, outpatient, concurrent, retrospective, and pre-service claims.

Reviewed medical necessity for hospital admissions, continued stays, outpatient procedures, and high-cost medications such as chemotherapy, for both adult and pediatric populations.

Conducted 20–22 reviews per day on average, ensuring timely and accurate determinations in line with clinical guidelines and payer policies.

Extensively utilized Optum360 claims processing system to support claim reviews and documentation workflows.

Collaborated with internal teams, healthcare providers, and clinical leadership to facilitate appropriate care decisions and ensure compliance with regulatory and accreditation standards.

Total Triage CareXM – Remote Jan 2019 to Nov 2021

Telephonic Triage RN (Part-time)

Fast-paced environment providing information and performing assessments to multi-state home health and hospice patients and their families, to determine the urgency of the medical issue, whether that issue could be resolved by the RN over the phone or whether a provider response or an ambulance transport was required.

Health Net Federal Services – Remote Feb 2016 to Jan 2017

RN Case Manager

Provided case management services for Veterans diagnosed with Hep C and requiring treatment outside of the VA Administration. Also ensured that Veterans with various other diagnoses were triaged to an appropriate civilian provider for continuation of care.

Caprock Health Plan – Remote Apr 2014 to Jan 2016

RN Case Management Supervisor

Supervised team of RNs for a TPA, providing case management services to chronically ill members.

WellMed/United Healthcare – Texas Jun 2010 to Apr 2014

Utilization Management Review RN

Conducted utilization management reviews for the Medicare Advantage population, evaluating the medical necessity of inpatient admissions, outpatient services, and procedures.

Collaborated with providers to ensure services met Medicare guidelines and supported timely, appropriate care coordination.

Ensured all determinations adhered to internal policies, CMS regulations, and evidence-based clinical criteria.

Vitas Hospice Healthcare – Texas Jan 2004 to Dec 2009

RN Case Manager

Provided home health case management to the terminally ill population.

Tucson Medical Center – Texas Jan 2001 to Dec 2003

Staff/Floor LVN/RN

Medical surgical unit

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