MARIA KRISTEL ORCENA

• Follow the Procedure Manual, apply client internal review criteria, medical policy, and other clinical guidelines to make medical necessity decisions.
• Conducts retrospective clinical claims review for care rendered during inpatient, outpatient and/or ancillary services for medical necessity, coding accuracy, medical policy compliance and contract compliance.
• Review providers’ requests for claims review and any associated clinical documentation/medical records attached, prepped and documented by the Claims team.
• Determine if complete clinical information for medical necessity review is attached/submitted. Prepare to return to claims team if incomplete documentation is received.
• Determine if the retrospective request can be approved by RN or if BSC Medical Director review is required.
• Consult with clinical reviewers and/or U.S. licensed medical directors as needed to ensure medically appropriate care throughout the process.
• Use available resources to understand contractual and regulatory compliance requirements and reports suspected compliance issues (including suspected data breaches) on the day of discovery to a Team Lead, Manager, and/or the Compliance Department.
• Ensures compliance with Accenture and Client policies at all times.

• Adheres to production and quality metrics.

• Provide nursing services to individuals admitted to COVID Facility.
• Performed accurate documentation of patient assessments, interventions, and outcomes.
• Collaborated with medical team.
• Improved patient satisfaction ratings by delivering compassionate and personalized care.
• Received and managed all clinic supplies
• Conducted ongoing monitoring and evaluations of behaviors and conditions, and updated clinical supervisors with current information.
• Provided excellent customer service while putting participants at ease.
• Handled minor emergencies related to allergies, anaphylaxis, and respiratory difficulty.
• Coordinated timely discharges by effectively communicating with physicians, nurses, social workers, and other relevant team members.
• Facilitated smooth transfers between hospital departments, minimizing delays in patient care during transition periods.
• Coordinated travel arrangements and contacted family with travel information.

• Resolved customer complaints with empathy, resulting in increased loyalty and repeat business.
• Addressed customer inquiries to ensure satisfaction and foster positive service experience.
• Handled escalated calls efficiently, finding satisfactory resolutions for both customers and the company alike.
• Enhanced customer satisfaction by promptly addressing concerns and providing accurate information.
• Developed strong product knowledge to provide informed recommendations based on individual customer needs.
• Developed rapport with customers through active listening skills, leading to higher retention rates and positive feedback from clients.
• Assisted customers in navigating company website, improving overall user experience.
• Maintained up-to-date knowledge on industry trends and regulations.
• Provided coaching and mentoring to new hires, contributing to their successful integration into the team.
• Mentored junior advisors, fostering a supportive team environment focused on growth and learning.
• Developed strong relationships with clients through regular communication and excellent customer service.
• Trained new Customer Service Representatives on company policies, procedures, and best practices.
• Improved client retention rates by developing and implementing comprehensive advisory plans to meet metrics.
• Worked with individuals to help understand and overcome personal, social or behavioral problems affecting working conditions.
• Boosted team morale by consistently recognizing colleagues' contributions and achievements.
• Analyzed customer service metrics to identify trends and develop strategies for improvement.

• Provided compassionate care for patients, resulting in positive feedback from families.
• Administered medications accurately and efficiently, ensuring proper dosages and timely treatments as prescribed by physicians.
• Facilitated smooth transitions between hospital discharge and home-based care through thorough communication with all parties involved.
• Monitored patient reactions after administering medications.
• Monitored vital signs regularly to detect and address potential health concerns promptly.
• Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
• Fostered strong relationships with clients and families to support comprehensive social, mental and physical care.
• Enhanced patient recovery by developing and implementing personalized care plans.
• Assessed patient needs routinely, adjusting care plans as necessary for the best results.
• Assisted patients with daily living activities, promoting dignity and independence.
• Implemented fall prevention strategies to minimize injury risk among vulnerable patients.

• Tend to newborns transitioning from extra uterine life.
• Optimized NICU environment to promote developmentally appropriate care for premature infants.
• Performed accurate documentation of patient assessments, interventions, and outcomes in compliance with regulatory standards.
• Conducted comprehensive assessments of neonatal patients to identify care needs and monitor progress.
• Administered medications via oral, IV, and intramuscular injections and monitored responses.
• Implemented infection control measures that significantly reduced hospital-acquired infections.
• Collaborated with interdisciplinary teams for optimized patient treatment plans and outcomes.
• Reduced medication errors through thorough double-checking of prescriptions and dosages.
• Provided emotional support to patients'' family members during critical incidents, strengthening overall trust in the healthcare team.
• Created an efficient shift handover process which improved continuity of care between nursing shifts.
• Communicated with healthcare team members to plan, implement and enhance treatment strategies.
• Recorded details regarding therapies to keep patient charts updated.
• Performed frequent checks on life support equipment and made necessary adjustments to preserve optimal patient conditions.
• Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.

• Maintained a sterile environment within the operating room, reducing the risk of infection.
• Coordinated with surgeons and staff to deliver safe patient care during operations.
• Implemented time-out protocols before starting surgeries, verifying correct patient identification and procedural details.
• Prepared equipment and supplies necessary for each surgical procedure, ensuring availability when needed by surgeons.
• Adapted quickly to changing situations in the operating room, utilizing problem-solving skills under pressure.
• Assisted physicians in operating room by providing necessary supplies and equipment.
• Performed pre-operative assessments to prepare patients for surgery.
• Prepped operating rooms to comply with environmental asepsis standards.
• Collected, labeled and transported specimens and delivered to lab for testing.
• Provided direct support to surgical team during procedures.
• Sanitized, selected and organizing instruments, equipment and supplies according to surgeon preferences.
• Managed efficient use of operating room resources, streamlining procedures and minimizing waste.
• Enhanced patient safety by implementing strict adherence to surgical protocols and guidelines.
• Coordinated with anesthesia providers to ensure proper administration of anesthesia during procedures.
• Served as a liaison between the surgical team and family members, providing timely updates on patient progress.
• Monitored patient reactions after administering medications and IV therapies.

• Collect primary data and initial assessment upon check-up appointment.
• Maintained detailed documentation of patient records, ensuring compliance with regulatory requirements.
• Evaluated patient histories, complaints, and current symptoms.
• Assisted physicians during examinations and procedures, providing expert clinical support as needed.
• Reduced medication errors, meticulously managing and dispensing medications according to physician orders.
• Administered medications accurately, adhering to strict protocols and safety guidelines.
• Developed strong rapport with patients, fostering trust and open communication for better understanding of their concerns.
• Administered vaccinations and improved community health awareness by organizing educational sessions.
• Improved patient satisfaction by delivering high-quality care and addressing individual needs.
• Reduced patient wait times by efficiently managing appointment schedules and optimizing clinic workflow.
• Managed inventory of medical supplies, maintaining adequate stock levels while minimizing waste.
• Improved patient safety with rigorous adherence to hygiene protocols and infection control measures.