ANGELICA RICO
Pomona,CA
Summary
Dedicated Utilization Review Nurse with over 11 years of experience in patient care and clinical documentation evaluation. Specializes in medical necessity assessment and insurance coverage review to ensure quality care aligns with cost-effective resource utilization. Collaborates effectively with providers and insurance partners to secure accurate and timely care authorizations.
Overview
11
11
years of professional experience
Work History
Utilization Review Nurse, RN
UCLA
Los Angeles, California
05.2026 - Current
- Reviews medical records to determine if services are medically necessary
- Applies clinical guidelines/criteria (e.g., InterQual, MCG, LCDs)
- Performs prior authorization reviews for procedures, medications, or services
- Ensures care is delivered in the appropriate setting (inpatient vs outpatient)
- Conducts concurrent and retrospective reviews of cases
- Issues or supports approval, modification, or denial decisions
- Collaborates with case managers, physicians, and other healthcare teams
Utilization Review Nurse, Letter Review Nurse, Team Lead RN
IEHP
Rancho Cucamonga, USA
08.2021 - 05.2026
- Led and coordinated a team of utilization review nurses, ensuring the timely completion of prospective, concurrent, and retrospective reviews.
- Improved clinical triage workflows to accelerate authorization decisions and reduce delays.
- Created member-focused denial letter templates and standardized letter review process to improve clarity and reduce rework.
- Applied clinical judgment using CMS, DHCS, MCG, and Apollo Managed Care guidelines to determine medical necessity and ensure compliant decisions.
- Collaborated with interdisciplinary teams to streamline review workflows and support patient-centered outcomes with measurable improvements.
- Tracked metrics and generated accurate reports using Microsoft Office to document case management activities and monitor performance.
Utilization Review Nurse (LVN)
Medix
Irvine, USA
03.2021 - 07.2021
- Reviewed patient charts and applied insurance guidelines to authorize or recommend denial of services, achieving measurable cost control and care alignment.
Utilization Review Nurse (LVN)
Agilon Health
Corona, USA
05.2017 - 09.2020
- Reviewed patient charts and applied insurance guidelines to authorize or recommend denial of services, achieving measurable cost control and care alignment.
Charge Nurse (LVN)
Gardenview Post Acute Rehab
Baldwin Park, USA
04.2015 - 05.2017
- Managed daily unit operations and staff scheduling, enhancing care continuity and ensuring regulatory compliance.
- Administered medications and performed resident assessments to maintain accurate care plans and safety.
- Updated individualized care plans and coordinated with physicians and families to address and resolve care issues.
- Supervised Certified Nursing Assistants, coaching to enhance care delivery and reinforce staff accountability.
- Ensured adherence to safety protocols and state regulations, resulting in measurable compliance improvements.
Education
RN BSN -
West Coast University
CASkills
- Clinical knowledge
- Microsoft Excel
- Microsoft Office
- Microsoft Word
- Critical thinking
- Communication
- Team work
- Multitasking
Timeline
Utilization Review Nurse, RN
UCLA
05.2026 - Current
Utilization Review Nurse, Letter Review Nurse, Team Lead RN
IEHP
08.2021 - 05.2026
Utilization Review Nurse (LVN)
Medix
03.2021 - 07.2021
Utilization Review Nurse (LVN)
Agilon Health
05.2017 - 09.2020
Charge Nurse (LVN)
Gardenview Post Acute Rehab
04.2015 - 05.2017
RN BSN -
West Coast University