Taguig, National Capital Region, Philippines
Dynamic and detail-oriented Nurse with extensive expertise in Utilization Review, Clinical Authorization, and Case Management across Pharmacy and Oncology services. I bring a strong background in conducting evidence-based reviews (MCG, InterQual) to ensure appropriate care, cost-effectiveness, and compliance with payer policies, regulatory standards, and healthcare best practices. Skilled in preparing clear and accurate clinical documentation, I collaborate effectively with providers, payers, and multidisciplinary teams to drive timely approvals, reduce denials, and support appeals with well-founded clinical justifications. Proficient in multiple EMR and UR platforms (EPIC, Cerner, Orinoco, InterQual) with deep knowledge of medical terminology, coding (CPT, HCPCS), payer systems (Medicare Part A–D, Medicaid, commercial insurance), and healthcare regulations (HIPAA). I consistently meet and exceed productivity, quality, and turnaround benchmarks while maintaining patient-centered decision-making. Unique qualities I bring: Proven ability to navigate complex oncology and pharmacy authorizations, including high-cost specialty medications and treatment regimens. Strong analytical skills with evidence-based decision-making in utilization management. Exceptional communication and documentation, ensuring clarity and accuracy across clinical and administrative teams. Adaptability to evolving payer policies, insurance regulations, and healthcare standards. With a balance of clinical expertise, regulatory knowledge, and operational efficiency, I position myself as a competitive and versatile nurse capable of excelling in high-stakes healthcare environments.
Clinical Authorization Nurse – Pharmacy & Oncology Conducted evidence-based clinical authorizations (MCG, InterQual) to ensure appropriate medication and oncology treatment approvals in alignment with payer policies, insurance requirements, and regulatory standards. Collaborated with providers and internal teams to gather clinical data and delivered clear, well-documented outcomes, including approvals, denials, and referrals for further review. Consistently achieved productivity, quality, and turnaround benchmarks while supporting appeals with detailed clinical justifications. Proficient in EMR systems (EPIC) with strong expertise in medical terminology, coding (CPT, HCPCS), payer requirements (Medicare Part A–D, Medicaid, commercial insurances), healthcare regulations (HIPAA), and utilization management guidelines (RCM).
Conducted evidence-based utilization reviews (MCG, InterQual) to ensure appropriate care and compliance with payer policies and regulatory standards. Collaborated with providers and internal teams to gather clinical data and delivered clear, well-documented review outcomes, including approvals, denials, and referrals. Consistently met productivity, quality, and turnaround benchmark. Proficient in EMR systems (Orinoco & Interqual) with proven expertise in medical terminology (CPT codes, HCPCs, Insurances, Medicare part A-D, Medicaid etc. ), healthcare regulations(HIPAA), and utilization management guidelines (RCM).