MA. ELOISA DELA CASA
Macon,Georgia
Summary
Professional Nurse with over 6 years experience in Utilization Review. Experienced with conducting thorough utilization reviews to ensure effective resource use and patient care. Utilizes clinical judgment to assess and evaluate ensuring compliance with healthcare regulations and improving patient outcomes.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Registered Nurse
Pruitthealth
02.2024 - 10.2024
- Utilized critical thinking skills to assess changes in patient conditions, recognize complications and intervene appropriately
- Managed multiple tasks while providing timely, high quality patient care
- Administered medications and treatments in accordance with physician orders and hospital policies
- Demonstrated strong communication skills to collaborate with interdisciplinary team members to ensure optimal patient outcomes
- Provided direct patient care, including assessment and evaluation of health status, development of individualized plans of care and implementation of nursing interventions.
Clinical Research Associate
PicnicHealth
05.2023 - 01.2024
- Reviews patient medical records to determine if they meet study inclusion criteria
- Works with physician researchers on developing cohort specifications and protocols
- Provides clinical expertise to help accurately extract and structure key medical concepts from patient records.
Utilization Review Nurse
Shearwater Health Advisors
03.2017 - 05.2023
- Performed utilization reviews for inpatient and outpatient services to ensure medical necessity, appropriateness of care and level of service according to state and federal regulations
- Managed daily workload efficiently by prioritizing tasks based on urgency and importance.
- Analyzed patient records to determine whether requested services met established criteria for medical necessity
- Coordinated appeals process between providers, members, payers and third party administrators regarding denied requests for services
- Provided feedback on denials and approvals to provider staff on a regular basis through verbal or written communication methods.
- Collaborated with physicians to clarify treatment plans, ensuring alignment with evidence-based practices.
- Reduced unnecessary medical costs, ensuring treatments met established medical guidelines and policies.
- Conducted thorough evaluations of medical necessity for procedures, leading to optimal resource utilization
Pulmonary Nurse
Breathe Always Good Air, Inc
05.2016 - 05.2017
- Determined respiratory therapy treatment plans in consultation with physicians and by prescription
- Helped patient accomplish treatment plan by administering inhalants; operating mechanical ventilators, therapeutic gas administration apparatus, environmental control systems, and aerosol generators
- Evaluated effects of respiratory therapy treatment plan by observing, noting, and evaluating patient's progress; recommending adjustments and modifications
Workers' Compensation Claims Assistant
Shearwater Health Advisors
08.2015 - 03.2017
- Verified client information by analyzing existing evidence on file.
- Assured timely verification of insurance benefits prior to patient procedures or appointments.
- Maintained confidentiality of patient finances, records, and health statuses.
- Processed and recorded new policies and claims.
- Prepared insurance claim forms or related documents and reviewed for completeness.
Complaint Analyst
Wipro BPO Philippines
02.2014 - 08.2015
- Maintained thorough working knowledge of all product information and procedures
- Ensured product complaint documentation, investigation, and review of all non-medical complaint content
- Provided quality customer service through coordination of return samples for investigation and follow-up activities such as replacement of product
- Conducted medical evaluations, gather information, communicate with medical professionals, end user, etc., for MDR determinations.
Education
Bachelor of Science - Nursing
University of San Carlos
Cebu City, Cebu04.2012
High School Diploma -
Holy Cross Academy
Tubigon, Bohol03-2008
Skills
- Utilization Review
- HIPAA Compliance
- Attention to Detail
- Clinical Judgment
- Teamwork and Collaboration
- Documentation and Charting
- Time Management
- Critical Thinking
- Utilization Management
- Interpersonal and written communication
- Task Prioritization
- Decision-Making
Certification
- Basic Life Support (eCard Code: 245602467943)
- Advanced Cardiovascular Life Support (eCard Code: 245622974175)
Licenses
• US Registered Nurse
Georgia Compact License No: RN328956
Texas License No: 917217
• Philippine Registered Nurse
License No: 0792447
Timeline
Registered Nurse
Pruitthealth
02.2024 - 10.2024
Clinical Research Associate
PicnicHealth
05.2023 - 01.2024
Utilization Review Nurse
Shearwater Health Advisors
03.2017 - 05.2023
Pulmonary Nurse
Breathe Always Good Air, Inc
05.2016 - 05.2017
Workers' Compensation Claims Assistant
Shearwater Health Advisors
08.2015 - 03.2017
Complaint Analyst
Wipro BPO Philippines
02.2014 - 08.2015
High School Diploma -
Holy Cross Academy
- Basic Life Support (eCard Code: 245602467943)
- Advanced Cardiovascular Life Support (eCard Code: 245622974175)
Bachelor of Science - Nursing
University of San Carlos
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