Amanda Pelayo

• Determined medical necessity and cost-effectiveness of services through utilization review processes.
• Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
• Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
• Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
• Collaborated with Interdisciplinary team in group meetings to identify issues and find cost-effective solutions.
• Kept detailed documentation on all utilization reviews by using EHR and EMR software.

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• Assessed patient needs and developed individualized plans of care.
• Monitored vital signs, including temperature, pulse, respiration rate, and blood pressure.
• Observed changes in the condition of patients and reported any significant findings to physicians or other healthcare professionals.

• Helped develop comprehensive resident assessment and care plans for 99-bed facility.
• Created and implemented care plans after reviewing patients' imaging and test results, working closely with other members of interdisciplinary team.
• Collaborated with interdisciplinary healthcare professionals to develop and modify individualized care plans for patients in multiple units.

• Collaborated with interdisciplinary healthcare team plan and implement effective treatment plans.
• Worked as a nurse supervisor as well as in case management obtaining insurance authorizations, including faxing necessary clinical documentation for review.
• Monitored patients, administered medications, ventilator and tracheostomy care, Foley catheter insertions, and wound care.