Summary
Overview
Work History
Education
Skills
Personal Information
Timeline
Generic

Nicole Mallo

Lutz,FL

Summary

Highly motivated and results-oriented registered nurse with over 18 years of experience in managed care, excelling in clinical coverage review, complex case management, and regulatory compliance. Proven ability to interpret state and federal mandates, apply benefit language, and analyze clinical information to make sound coverage determinations. Skilled in collaborating with healthcare providers and internal teams to ensure quality care delivery and adherence to guidelines. Adept at working independently and in a team environment to meet performance metrics and achieve departmental goals.

Overview

19
19
years of professional experience

Work History

Senior Compliance Nurse

CarePlus Health Plans
10.2021 - 05.2024
  • Performed clinical coverage reviews, interpreting state and federal regulations, benefit language, and relevant clinical data to determine coverage eligibility
  • Functioned as a key member of a team, collaborating with Medical Directors and non-clinical partners to achieve performance goals
  • Communicated effectively in writing and verbally, explaining coverage determinations to healthcare providers and members, and obtaining additional clinical information through telephonic discussions
  • Served as a resource for less experienced staff, providing guidance and support on complex clinical cases and regulatory requirements

Performance Monitoring Specialist, Utilization Management Pre-Certification and Appeals

Centene (Formerly WellCare Health Plans)
05.2012 - 03.2021
  • Conducted comprehensive clinical coverage reviews, ensuring accuracy and compliance with Medicare, Medicaid regulations, and contractual obligations
  • Collaborated with a team to develop and implement audit tools to monitor adherence to quality standards and identify areas for improvement
  • Effectively communicated complex compliance and quality of care issues to leadership, recommending solutions and driving process improvements
  • Mentored and trained new hires, fostering a collaborative and high-performing team environment

Prior Authorization Review Nurse

Centene (Formerly WellCare Health Plans)
05.2006 - 05.2012
  • Independently reviewed and processed prior authorization requests, applying medical guidelines and policies to make informed coverage decisions
  • Demonstrated strong analytical skills in assessing medical necessity, benefits, and clinical appropriateness of care requests
  • Effectively communicated with providers to clarify requests and educate them on utilization management processes

Suncoast Dialysis
09.2005 - 05.2006

Tampa General Hospital
01.2005 - 09.2005

Education

Associate of Science - Nursing

Hillsborough Community College
01.2004

Bachelor of Arts - Social Sciences

Florida Atlantic University
01.2002

Skills

  • Medicare and Medicaid regulations
  • NCQA standards
  • MCG criteria
  • InterQual criteria
  • CMS criteria
  • Written communication
  • Verbal communication
  • Microsoft Office Suite
  • Excel
  • Word
  • Outlook
  • Time management
  • Multitasking
  • Prioritization
  • Clinical documentation
  • Clinical judgment
  • Patient management
  • Compassionate care
  • Licensed RN
  • Healthcare ethics
  • Health promotion
  • Care coordination
  • Licensed by FL nursing board, multistate

Personal Information

License: FL license # RN9230228

Timeline

Senior Compliance Nurse

CarePlus Health Plans
10.2021 - 05.2024

Performance Monitoring Specialist, Utilization Management Pre-Certification and Appeals

Centene (Formerly WellCare Health Plans)
05.2012 - 03.2021

Prior Authorization Review Nurse

Centene (Formerly WellCare Health Plans)
05.2006 - 05.2012

Suncoast Dialysis
09.2005 - 05.2006

Tampa General Hospital
01.2005 - 09.2005

Bachelor of Arts - Social Sciences

Florida Atlantic University

Associate of Science - Nursing

Hillsborough Community College

Similar Profiles

CREATE PROFILE
Nicole Mallo