Dedicated and dual-licensed Registered Nurse (Philippines and United States) with over 5 years of specialized experience in Clinical Utilization Management, focusing on preservice and inpatient utilization review. Proficient in applying evidence-based guidelines such as MCG and InterQual to assess medical necessity, appropriateness of care, and compliance with payer and regulatory requirements.
Experienced in conducting outbound calls to communicate case determinations to patients, healthcare facilities, and requesting providers, ensuring clarity, timeliness, and compassionate communication. Skilled in handling both approvals and denials professionally, while maintaining HIPAA compliance and supporting care coordination efforts.
Adept at reviewing clinical documentation, collaborating with multidisciplinary teams, and facilitating authorizations to promote cost-effective, high-quality patient outcomes. Known for strong clinical judgment, attention to detail, and the ability to balance patient advocacy with payer expectations.
