Angela Mae Tan
Rosedale
Summary
- RN with 3 years of acute care experience in the medical-surgical unit and over 6 years of experience in utilization review, eager to leverage my clinical experience and skills to perform medical necessity reviews for inpatient admissions and outpatient services, utilizing evidence-based clinical guidelines, medical policy, and federal and state mandates in order to provide quality and cost-effective care.
- Active, Compact, Registered Nurse License in the State of Maryland.
- Bachelor's of Science in Nursing (BSN) graduate.
- Specialized in the healthcare utilization management industry, doing utilization review for major U.S. health plans and managed care models for over five years.
- Experience in various UM lines of business, such as Commercial Health Plan, Medicare, and Medicaid.
- Proficient knowledge of Milliman Care Guidelines and InterQual.
- Keen on the dynamics and logistics of working in a remote/hybrid setup, and highly efficient in Microsoft Office applications.
Overview
16
16
years of professional experience
1
1
Certification
Work History
UTILIZATION MANAGEMENT NURSE CONSULTANT
CVS Aetna
05.2025 - Current
- Utilizes clinical experience and skills in a collaborative process to assess, plan, implement, coordinate, monitor and evaluate options to facilitate appropriate healthcare services/benefits for members.
- Perform utilization review activities, including concurrent reviews of acute admissions and pre-certification for post-acute (e.g., SNF, AIR, LTACH) using evidence-based criteria (e.g., InterQual, MCG, CMS).
- Ensures accurate documentation of rate negotiations for appropriate claims adjudication.
- Collaborate with attending providers, case managers, and multidisciplinary teams to coordinate care, facilitate safe transitions, and advocate for optimal outcomes.
- Ensure medical necessity, appropriateness, and length-of-stay determinations align with contractual, regulatory, and accreditation organizations (e.g., Medicaid, CMS, NCQA).
- Prepares case review for the Medical Director in cases where criteria are not met based on the additional clinical information received.
- Communicate clinical decisions to providers and member families with empathy and clarity.
- Sends appropriate system-generated letters to provider and member.
- Identify barriers to care, escalate complex cases, and participate in interdisciplinary rounds as needed.
- Support discharge planning and transition of care, engaging with families to address social determinants and unique member needs.
- Maintain accurate, timely documentation in UM systems, ensuring data integrity, compliance with company policy, and adherence to each CMS-mandated turnaround time (TAT).
- Participate in quality improvement, policy review, and education related to utilization management.
- Provides guidance and coaching to other utilization review nurses and participate in the orientation of newly hired utilization nurses
- Consults and lends expertise to other internal and external constituents in the coordination and administration of the utilization/benefit management function.
- Follows all departmental policies and workflows in handling cases.
UTILIZATION REVIEW NURSE
Nexus
03.2023 - 12.2024
- Performs medical necessity reviews by referencing appropriate criteria/guidelines which include but are not limited to regulatory mandates, contracts, eligibility and benefit information, Milliman Care Guidelines, Medicare Guidelines, Federal Employee Program and Policy Guidelines, Medical Policy, and other accepted medical/pharmaceutical references (i.e. FDA, Drugs.com, UpToDate, National Institute of Health, etc.)
- Analyzes patient records to ensure optimal patient outcomes, high-quality and cost-effective care in compliance with Federal and State regulations.
- Conducts inpatient admission reviews to determine claim payment based on Company policies.
- Identifies appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
- Conducts research and analysis of pertinent diseases, treatments and emerging technologies, to support decisions and recommendations made to the medical directors.
- Reviews and completes all clinical service requests within required timelines.
- Identifies missing information from clinical documentation and requests additional information from members or providers as needed.
- Makes appropriate referrals to other clinical programs.
- Collaborates with medical directors, healthcare providers, members, and multidisciplinary teams to ensure medically appropriate, high quality and cost-effective care to members throughout the utilization management process.
- Conducted care coordination for a member's transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
- Adheres to UM policies and departmental protocols/standard operating procedures.
- Performs other duties as assigned.
CLINICAL MANAGER
Fayette Health and Rehabilitation Center
Baltimore
08.2022 - 01.2023
- Supervises, counsels, and provides discipline when necessary to nurse staff to ensure the highest quality care possible.
- Directs day-to-day nursing operations, including patient assessments, care planning, and staff assignments.
- Ensures the unit meets federal and state regulatory standards as well as company policies and procedures.
- Develops and implements training programs to enhance nursing staff skills and competencies.
- Collaborates with the healthcare team to plan and maintain resident care.
- Completes admission and discharge assessments.
- Assists in developing, implementing, and making adjustments to patient care plans as needed.
CLINICAL APPEALS RN
Optum Global Solutions
Taguig City
05.2018 - 06.2022
- Facilitates medical necessity appeals and denials including disposition of denials notification letters, review of clinical information to determine if medical necessity criteria are met.
- Assesses inpatient admissions and outpatient services for members to ensure optimal outcomes, cost effectiveness and compliance with all state and federal regulations and mandates.
- Performs prospective, concurrent, and retrospective medical record reviews utilizing approved clinical criteria to determine claim payment based on company policies, including overturning denied claims, upholding the denials and submitting cases to the Medical Director for review.
- Reviews and completes all provider clinical appeals within required timeframes.
- Analyzes medical documentation to assist with documenting a clear and concise clinically based argument to overturn or uphold denials received.
- Perform research related to the facts and circumstances of an appeal.
- Upholds HIPPA guidelines regarding PHI.
- Collaborates with subject matter experts within the organization to obtain benefit and/or clinical opinions/interpretation based on complex cases.
PUBLIC HEALTH NURSE
Department of Health - NCRO
Mandaluyong City
10.2017 - 12.2017
- Supervises support staff.
- Conducts regular visits to priority households with health problems.
- Prepares health status reports of families/households visited.
- Plans for appropriate interventions on the identified health concerns of families/households.
- Assists in the conduct of regular monitoring and evaluation of various health programs.
- Assists in the conduct of disease surveillance.
- Conducts health education and training.
STORE NURSE
Metro Department Store
Quezon City
05.2017 - 10.2017
- Ensure that customers and employees receive timely and appropriate medical attention especially in the events of workplace injuries and prescribes medical treatment and personal health care services to those who seek medications or consultations.
REGISTERED NURSE
Medeor Medical Center
Abu Dhabi
11.2014 - 04.2016
- Consults and coordinates with health care team members.
- Prepares and administers medication (orally, subcutaneously, through an IM/IV).
- Reports adverse reactions to medications or treatments to the physician.
- Records patients' medical information and vital signs.
- Instructs patients regarding health promotion and disease management.
- Prepares equipment and aids physician during examination and treatment of patient.
- Documents all care rendered properly.
- Performs other position-related duties as assigned.
STAFF NURSE / CHARGE NURSE
Manila Jockey Club, Inc
Pasig City
01.2014 - 10.2014
- Provides general patient care and basic patient education.
- Schedules and coordinates paperwork for employee patient / doctor appointments and consultations; assesses reasons for employee visit.
- Reviews employees medical records, obtains and records employee's weight, blood pressure, laboratory results and medical history.
- Records and reports observed symptoms, reactions, treatments, and changes in the patient's condition.
- Administers medications; applies sterile dressings.
- Organizes quarterly medical missions conducted by the company.
- Performs other job-related duties as assigned.
STAFF NURSE / CHARGE NURSE
Dr. Jose Rodriguez N. Memorial Hospital
Caloocan City
01.2013 - 12.2013
- Coordinating daily administrative duties, including schedules, nursing assignments, and patient care.
- Supervising staff and overseeing their needs.
- Performs direct nursing care procedures and services: patient admission and discharge, hygiene care, vital signs, pre and post-operative nursing care.
- Observes, records, and reports patient's symptoms, conditions, and progress of treatment and management.
- Prepares patient and assist doctors with diagnostic, surgical, and therapeutic procedures.
- Administers medication as ordered and notes any reaction.
- Performs essential procedures such as Oral Feeding via NGT, IVT Insertion, IVF Therapy, urethral catheterization, nebulization with chest physiotherapy, sterile dressings, etc.
- Communicates effectively with incoming shifts regarding status of the unit and the patient (proper endorsement).
- Performs other related tasks and functions as delegated from time to time.
COMPANY NURSE
Manila Jockey Club, Inc.
Pasig City
09.2009 - 12.2012
- Provides general patient care and basic patient education.
- Schedules and coordinates paperwork for employee patient / doctor appointments and consultations; assesses reasons for employee visit.
- Reviews employees medical records, obtains and records employee's weight, blood pressure, laboratory results and medical history.
- Records and reports observed symptoms, reactions, treatments, and changes in the patient's condition.
- Administers medications; applies sterile dressings.
- Performs other job-related duties as assigned.
Education
Bachelor of Science - Nursing
Our Lady of Fatima University
Quezon City, Philippines03.2009
Skills
- Strong oral and written communication skills
- Strong clinical judgment and critical thinking skills are needed to evaluate complex cases and determine appropriate levels of care
- Strong communication and interpersonal skills to coordinate with a multidisciplinary team
- Ability to work independently and collaboratively within a team environment, while maintaining productivity and compliance with HIPAA
- Computer skills: proficient in using MS Word, Excel, PowerPoint, Outlook, and electronic medical records
- Ability to maintain and manage daily case review assignments, with a high emphasis on quality
- Ability to multitask and adapt in a fast-paced environment
- Excellent time management and work prioritization skills
- Strong organizational and task prioritization skills
Certification
- NCLEX-RN, Maryland, R256388, 10/13/22, 05/28/26
- NCLEX-RN, Connecticut, 157492, 06/01/19, 05/31/25
References
Available Upon Request
Personal Information
Title: RN, BSN
Timeline
UTILIZATION MANAGEMENT NURSE CONSULTANT
CVS Aetna
05.2025 - Current
UTILIZATION REVIEW NURSE
Nexus
03.2023 - 12.2024
CLINICAL MANAGER
Fayette Health and Rehabilitation Center
08.2022 - 01.2023
CLINICAL APPEALS RN
Optum Global Solutions
05.2018 - 06.2022
PUBLIC HEALTH NURSE
Department of Health - NCRO
10.2017 - 12.2017
STORE NURSE
Metro Department Store
05.2017 - 10.2017
REGISTERED NURSE
Medeor Medical Center
11.2014 - 04.2016
STAFF NURSE / CHARGE NURSE
Manila Jockey Club, Inc
01.2014 - 10.2014
STAFF NURSE / CHARGE NURSE
Dr. Jose Rodriguez N. Memorial Hospital
01.2013 - 12.2013
COMPANY NURSE
Manila Jockey Club, Inc.
09.2009 - 12.2012
Bachelor of Science - Nursing
Our Lady of Fatima University