MARY JOY AREVALO
Eagan,MN
Summary
Dynamic Registered Nurse with experience in Utilization Review and ER, excelling in medical necessity evaluations. Proven ability to enhance patient care through evidence-based evaluations and effective team coordination. Skilled in utilizing InterQual criteria to optimize healthcare delivery while ensuring compliance with utilization guidelines.
Overview
15
15
years of professional experience
3
3
Certifications
Work History
Utilization Review Nurse
UnitedHealth Group
Eden Prairie, Minnesota
08.2022 - Current
- Conducted comprehensive reviews of patient care plans for medical necessity.
- Collaborated with healthcare providers to ensure compliance with utilization guidelines.
- Analyzed patient data using clinical software for accurate decision-making.
- Communicated effectively with interdisciplinary teams to coordinate care strategies.
- Developed and maintained documentation standards for review findings and recommendations.
- Performed pre-certification, concurrent, and retrospective reviews of inpatient and outpatient services medical and behavioral cases.
Registered Nurse, TCU
Presbyterian Homes of Bloomington
Bloomington, Minnesota
01.2019 - 07.2022
- Informed physicians of changes in patient conditions and nursing needs.
- Educated patients and families on conditions, treatments, and possible outcomes.
- Identified deviations and wellness changes and made recommendations, adjustments, and reports.
- Trained, guided, and managed new staff on nursing procedures.
- Kept accurate and complete records for each patients.
- Collaborated with other medical and social service organizations to coordinate continuum of care.
Utilization Review Nurse, Triage Nurse
Shearwater Health Advisors
Taguig, PH
09.2016 - 12.2018
- Evaluated medical necessity, delivery, cost-effectiveness, and appropriate use of healthcare services on a prospective, concurrent, or retrospective basis.
- Determined appropriate chart, telephonic, and written justification by analyzing charges, reimbursement, and contract information.
- Compared requests for medical services against evidence-based treatment guidelines and make recommendations based on that comparison.
- Answered patient calls and addressed wide range of concerns, symptoms, and medication side effects.
Inpatient Care Manager
UnitedHealth Group
Taguig, PH
06.2013 - 06.2016
- Performed utilization and concurrent review of inpatient cases using Milliman criteria.
- Discussed cases with treating physicians and other healthcare professionals to better understand plans-of-care.
- Identified and evaluated delays in care.
- Arranged alternative care services, contacting and maintaining communication with acute long term care, acute rehabilitation or skilled nursing facilities to move patients through the care continuum.
ER/Trauma Registered Nurse
Ministry of Health
Buraimi, Oman
06.2011 - 06.2013
- Assisted trauma doctors in emergency situations, monitoring vital signs and signs of complications.
- Performed emergency procedures such as CPR and inserting intravenous lines to mitigate heart failure or enable oxygen flow.
- Handled serious injuries and illnesses, such as car accidents and heart attacks.
- Administered local, intravenous and inhalation anesthetics based on patient conditions and procedural requirements.
Education
Bachelor of Science - Nursing
Universidad de Sta. Isabel
Naga, PhilippinesSkills
- Patient assessments
- Medication administration
- Team coordination
- Multitasking
- Prioritization
- Evidence-based evaluation
- Interdisciplinary collaboration
- InterQual criteria
- Medical necessity review
- Utilization management
Languages
English
Professional
Filipino/Tagalog
Professional
Certification
Certified Case Manager
Timeline
Utilization Review Nurse
UnitedHealth Group
08.2022 - Current
Registered Nurse, TCU
Presbyterian Homes of Bloomington
01.2019 - 07.2022
Utilization Review Nurse, Triage Nurse
Shearwater Health Advisors
09.2016 - 12.2018
Inpatient Care Manager
UnitedHealth Group
06.2013 - 06.2016
ER/Trauma Registered Nurse
Ministry of Health
06.2011 - 06.2013
Bachelor of Science - Nursing
Universidad de Sta. Isabel