ANABELLE TORIO
Las Vegas
Summary
Registered Nurse with specialized experience in clinical claims review and utilization management across inpatient and outpatient settings. Skilled in verifying service documentation accuracy, identifying discrepancies, and conducting medical necessity reviews aligned with payer policies and guidelines. Certified Quality Auditor with a strong history in mentoring clinical teams, launching training programs, and leading cross-functional process improvement initiatives. Known for autonomous workflow management, cross-team collaboration, and high standards in regulatory compliance and patient-centered care.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Clinical Trainer & Clinical Claims Reviewer (Anthe
EXL Service (2018-2021) | Carelon Global Solutions
12.2018 - 11.2022
- Conducted clinical claims reviews for inpatient and outpatient services, ensuring documentation accuracy and medical necessity in accordance with URAC standards for clinical review quality and compliance.
- Validated service documentation and billing accuracy prior to medical necessity review to ensure integrity of claims and prevent discrepancies.
- Delivered preprocessing, process training, nesting, mentoring, and cross-training across multiple review teams.
- Supported launch of Government Business Division with trainer onboarding and review team development.
- Partnered with India-based claims processors to identify and correct patterns of misrouted cases, improving claims flow accuracy.
- Participated in high-volume post-service clinical claims reviews and supported overflow operations.
- Contributed strategic input during macro brainstorming sessions aimed at increasing productivity across review teams.
Home Health RN
Arrow Home Health
03.2024 - Current
- Coordinated care plans with PT, OT, and Speech professionals, educating patients and families for optimal recovery.
- Maintained clear documentation and independent decision-making across home health cases.
Staff Nurse – Geriatric Psychiatry / Med-Surg Float
North Vista Hospital
09.2023 - Current
- Delivered individualized psychiatric care to geriatric patients and facilitated therapeutic group sessions to improve outcomes.
- Documented patient care plans and coordinated with multidisciplinary teams to ensure continuity of treatment.
- Floated to Med-Surg unit, adapting to dynamic patient needs and varied clinical challenges.
Charge Nurse – Transitional Care Unit
PureHealth
02.2023 - 08.2023
- Oversaw patient recovery plans and conducted timely assessments to reduce risk and improve outcomes.
- Educated families on health trends and interventions for smoother transitions.
Private Duty Nurse – Pediatrics
Al Thani Royal Family Palace
01.2016 - 01.2018
- Delivered personalized infant care including medication administration and developmental assessments.
- Scheduled well-child visits and maintained organized health records.
Clinic Nurse
Torio Maternity and Medical Clinic
01.2009 - 01.2011
- Provided care and education to women and children; supported diagnostic testing and screenings.
Education
Bachelor of Science - Nursing
University of the Cordilleras
01.2009
Skills
- Utilization Review
- URAC-aligned compliance
- Claims Verification
- Medical Record Analysis
- Familiarity with HCPCS/CPT/ICD Coding
- MCG Guidelines
- InterQual (Introductory Use)
- Quality Auditing
- HIPAA Compliance
- Mentoring & Training
- Workflow Optimization
- Microsoft Office (Word, Excel, Outlook)
Certification
- - Basic Life Support – AHA
- - IV Therapy Training – National Kidney and Transplant Institute
- - Certified Quality Auditor (Tenure Valid: 2018–2022)
- RN: Nevada, Florida, Texas, New York
Timeline
Home Health RN
Arrow Home Health
03.2024 - Current
Staff Nurse – Geriatric Psychiatry / Med-Surg Float
North Vista Hospital
09.2023 - Current
Charge Nurse – Transitional Care Unit
PureHealth
02.2023 - 08.2023
Clinical Trainer & Clinical Claims Reviewer (Anthe
EXL Service (2018-2021) | Carelon Global Solutions
12.2018 - 11.2022
Private Duty Nurse – Pediatrics
Al Thani Royal Family Palace
01.2016 - 01.2018
Clinic Nurse
Torio Maternity and Medical Clinic
01.2009 - 01.2011
Bachelor of Science - Nursing
University of the Cordilleras
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