Utilization Review LVN

Brenda S. Mendoza

Schertz, TX -- 210-***-**** -- **************@*****.***

Utilization Review Nurse and Clinical Professional

Utilization review

Clinical Documentation

Clinical Competency

Prior Authorization

Fluent in Spanish

Team Collaboration

Critical Thinking

Customer Service

Interpersonal Communication

Organizational Skills

Attention to Detail

Time Management

Insurance Verification

Microsoft Office

Knowledge of TruCare

Professional Summary

WellMed/United Healthcare

San Antonio, TX -- April 2022 – December 2025

Utilization Management Nurse

Supported clinical decision-making by collaborating with providers, pharmacists, and medical directors to ensure appropriate, safe, and cost-effective patient care. Responsibilities included gathering and summarizing clinical information for review and researching treatment guidelines. Applied pharmacological and clinical guidelines to assess appropriateness of care, and advocates for optimal patient outcomes. Knowledge of utilization management processes, clinical criteria (e.g., Milliman, CMS, medical policy), and the ability to solve problems, interpret policies, and contribute to process improvements. Additional duties were performed as assigned.

Nexus Medical Consulting

Schertz, TX -- August 2019 – January 2022

Utilization Review Nurse

Performed a review of services for medical appropriateness utilizing pre-approved criteria and guidelines to validate medical necessity/appropriateness of treatment (e.g., ODG, MTUS, Milliman Care Guidelines, InterQual)

Audited and analyzed patient records to ensure quality patient care and necessity of services. Entered and maintained pertinent clinical information in various medical management systems. Used clinical logic and reasoning to determine appropriate evidence-based guidelines. Facilitated cost effective and quality patient care by effective communication with managerial team, physicians, and Medical Director.

WellMed

San Antonio, TX. – March 2018 – August 2019

LVN-Patient Service Center

Managed inbound calls from patients, patient representatives, providers, and other medical staff. Practiced quality clinical skills and adhered to established protocols for handling patient inquiries and requests. Worked collaboratively with clinic staff and other departments to provide exceptional patient experience. Worked effectively in a structured environment to manage incoming contacts including, but not limited to, prescription refill requests, lab results, x-ray results, medical inquiries and referral requests. Assisted callers with general contacts including, but not limited to, appointment scheduling, general facility and provider information, general requests, medical records requests, and issue resolution. Verified and updated patient information in the clinical information system. When appropriate, assigned electronic tasks to clinic staff to intervene with medically related inquiries and requests. Reviewed patient chart (in EMR) to ensure core measures were being addressed, met protocol, and took appropriate action when they were not. Documented thoroughly all calls and actions taken within core systems.

ObesityPPM

San Antonio, TX. – October 2015 – January 2018

Director of Contact Center Services

Working from home in a virtual environment managing a team of contact center consultants located throughout the United States. Full operational accountability for all contact center services. Hiring/Dismissal authority for Contact Center Consultants, final decision maker regarding hiring choices. Achievement of Service Level Agreements (contracted and company-determined) and customer satisfaction. Achievement of customer business objectives (customer-specific); for example, achieving certain event attendance rates, increases in case volume, improved conversion from one milestone to another, protocol adherence, patient retention. Responsible for compliance with all Obesity PPM legal requirements while doing business to include HIPAA, HITECH Act, and CAN-SPAM under the guidance of our Compliance Officer. Contact Center Consultant recruiting, job satisfaction, retention, and professional development.

JasoMD Surgical Practice

San Antonio, TX. – December 2012 to October 2015

Practice Manager/LVN

Restructured the practice resulting in an efficient and strong bariatric and general surgery practice

Managed the office on both the clinical and administrative side

Developed a strong bariatric program with clear and effective clinical pathways

Verified patient insurance benefits for general, vein and bariatric cases

Prepared insurance authorization submissions for all General, Vein and Bariatric cases ensuring all insurance criteria had been met based on medical policy

Developed Pre- and Post-operative Patient Education Classes

Ensured clinical staff were consistent in following protocols to ensure the best outcomes for our patients

Reviewed lab and test results and notified the surgeon of all abnormal results

Ensured patients met all clinical requirements prior to surgery and handled all surgery scheduling

Total Health Primary Care

Schertz, TX. – March 2012 to December 2012

Practice Manager/LVN

Managed a busy family practice with two doctors and one Physician Assistant. Handled all hiring and if necessary, dismissals. Managed both clinical and administrative staff to ensure clinic was working efficiently. Verified patient insurance benefits. Training and management of the Insurance Specialists and Referral Coordinator. Triaged patients whenever necessary to keep the clinic flow running smoothly. Reviewed lab and test results and notified physicians of all abnormal results. Provided injections and IVs. Managed the billing for the clinic to ensure timely submissions to insurances. Initiated the training of all staff on the new Athena EMR.

Texas Bariatric Specialists

San Antonio, TX. – August 2008 to February 2012

Insurance Director/LVN

Assisted the practice in reorganizing and building the quality and success rate of the Insurance department specifically in securing insurance approvals for bariatric surgical candidates.

Coordinated the insurance process from intake to approval to include handling all Denial and Appeal cases for the practice

Trained and managed Insurance Specialists/Patient Advocates

Provided Pre-and Post-operative Patient Education Classes

Assisted in developing and customizing EMR programs to ensure efficient patient tracking

Served as part of the key leadership team for the Practice

Innova Hospital San Antonio

San Antonio, TX. – November 2006 to April 2008

Bariatric Program Director

Coordinated and directed the day-to-day activities of hospital’s Bariatric Surgical Weight Loss Program in accordance with established hospital policies to provide high quality health care services. My knowledge of the field's concepts, practices, and procedures, in addition to my extensive experience and judgment allowed me to plan, implement and accomplish goals. Supervisory responsibility for the Bariatric Clinic Nurse, Medical Assistants, Registered Dietitian, Insurance Verifiers, Bariatric Insurance Specialists and Clinic Clerks. Superior customer service skills; ability to develop relationships with patients, physicians and insurance personnel; professionalism; multi-tasking; organizational skills; ability to work well in an ever-changing environment; positive attitude; excellent communication and computer skills and strong ability to prioritize.

Education and Professional Training

Currently LVN licensed from the Texas Board of Nursing (effective 7/15/2010)

Honors Graduate with Kaplan Nursing College, San Antonio, TX

Bilingual in Spanish

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