Medical Auditor - Utilization Review & Clinical Documentation

CV ****

CARLA JANAINA MONTI DE CERQUEIRA PATTERSON, MD

Houston, TX

Email: ****************@*****.***

Phone: +1-832-***-****

LinkedIn: http://linkedin.com/in/carla-cerqueira-wakamatsu-0789b2178 PROFESSIONAL SUMMARY

Internationally trained Medical Doctor with extensive experience in medical audit, utilization review, clinical documentation, and quality-focused healthcare functions. Strong background in hospital- based care, including approximately 10 years in intensive care and emergency medicine, with proven ability to apply evidence-based clinical judgment to medical necessity determination, authorization processes, and complex case review. Experienced in bridging clinical practice and administrative decision-making to support patient safety, quality standards, and cost-effective care. CORE SKILLS

• Clinical Documentation Review

• Utilization Review & Medical Necessity Determination

• Medical Audit (Internal & External)

• Authorization of Medical Procedures

• Evidence-Based Medicine

• Quality Improvement & Patient Safety

• Chart Review & Case Analysis

•High-Cost & Complex Case Evaluation

• Interdisciplinary Clinical Communication

• Hospital-Based Care (ICU & Emergency)

PROFESSIONAL EXPERIENCE

Medical Auditor – Internal & External

Geap Auto Gestão Brazil

October 2021 – January 2024

• Conducted internal and external medical audits, reviewing clinical documentation for compliance, accuracy, and medical necessity.

•Evaluated authorization requests for medical procedures and treatments using evidence-based guidelines and institutional policies.

• Analyzed low- and high-cost cases, supporting defensible medical determinations and cost-effective care decisions.

• Served as a liaison between clinical and administrative teams to clarify documentation gaps and optimize utilization.

Medical Auditor – External & Internal Accounts

Unimed Rio Brazil

2004 – 2008

•Performed comprehensive audits of internal and external medical accounts across low- and high-complexity cases.

• Reviewed clinical records to assess appropriateness of care, level of service, and alignment with established clinical standards.

•Supported utilization control strategies while maintaining patient-centered decision-making.

Medical Reviewer / Authorization Physician

Grupo de Saúde Assim Brazil

• Conducted medical reviews for procedure authorization and inpatient care requests.

•Evaluated hospitalized patient cases to assess overall clinical management and appropriateness of requested services.

• Reviewed physician requests within the health system, balancing clinical benefit, patient safety, and organizational cost considerations. Intensive Care Physician (ICU)

Multiple Hospitals Brazil

Approx. 10 years

• Provided care to critically ill adult patients in ICU settings.

• Participated in multidisciplinary rounds and complex clinical decision-making.

• Managed high-acuity cases requiring advanced monitoring and intervention. Emergency Physician

Multiple Hospitals Brazil

Approx. 10 years

• Delivered emergency medical care in high-volume emergency departments.

• Managed acute and critical presentations across varying levels of acuity.

• Supervised junior physicians and trainees in emergency settings. EDUCATION

• Doctor of Medicine (MD) – Faculdade de Tecnologia e Ciências Médicas

(FTESM), Brazil

1996 – 2001

• Postgraduate Training in Clinical Cardiology – Instituto Nacional de Cardiologia de Laranjeiras, Brazil

(Completed)

• Healthcare Management with Emphasis on Medical Audit – Estácio Completed: 2021

• Member – Sociedade Brasileira de Auditoria Médica LANGUAGES

•Portuguese – Native

•English – Fluent

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