Philippine Registered Nurse

Conducted comprehensive audits of patient records, ensuring 100% compliance with regulatory and insurance requirements using software tools. Maintained quality standards above 95%. Handled medical and surgical treatment requests such as rehabilitation programs, medications (oral and injections), DMEs, surgeries, mental and behavioral programs, and chronic pain management programs. Coordinated with physician reviewers via telephone and email and follows up timely to obtain and deliver determinations. Collaborated with Intake and Clinical Management Teams to resolve complex patient cases and improve workflow accuracy.

Utilized Electronic Health Record (EHR) systems to accurately document patient demographics, clinical data, and treatment plans with 98–99?curacy. Reviewed and audited medical records to ensure completeness, medical necessity, and compliance with HIPAA and regulatory standards. Supported utilization management processes (prior authorization, concurrent, retrospective, and appeals review) through efficient EHR navigation. Extracted and summarized clinical data for physician reviewers and multidisciplinary teams to support care decisions. Identified documentation gaps and implemented quality improvements to enhance data integrity and workflow efficiency. Trained and onboarded staff on EHR systems, documentation standards, and intake protocols.

Led capacity planning initiatives across multiple healthcare programs, aligning staffing models with client demand and service level agreements (SLAs). Forecasted workload volumes using historical data and trend analysis to ensure optimal staffing and resource allocation. Developed and maintained staffing models to support patient intake, utilization management, and clinical operations. Monitored real-time performance metrics (productivity, turnaround time, queue volumes) to proactively address capacity gaps.

Provided comprehensive nursing care across multiple medical and surgical departments, ensuring high standards of patient safety and quality care. Maintained accurate and detailed clinical documentation to support continuity of care and regulatory compliance. Supported patient admission and discharge documentation processes. Collaborated with multidisciplinary teams to ensure seamless patient transitions and accurate documentation.