Stephanie Reyestan
Edinburg,TX
Summary
Utilization Review Nurse experienced in clinical documentation improvement and application of Optum's InterQual clinical decision-support criteria. Ensured accurate and complete documentation of treatments, supporting correct coding, reimbursement, and quality reporting through strong clinical judgment and critical thinking in high-intensity healthcare environments.
Overview
1
1
Certification
22
22
years of professional experience
Work History
Utilization Review Nurse
Centene Corporation
10.2018 - 10.2026
- Assessed medical necessity using InterQual and Milliman criteria.
- Coordinated care with physicians, case managers, and member services teams.
- Evaluated appeals and reconsiderations for clinical accuracy and policy compliance.
- Tracked referrals, admissions, and discharge plans across care settings.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Applied state and federal regulations to utilization review decisions.
- Served as a resource for staff members seeking guidance on utilization review matters.
- Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.
- Applied medical criteria and clinical judgment to researched cases to evaluate and establish determinations.
- Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
- Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries.
- Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions.
- Communicated with external partners such as managed care organizations or vendors on a regular basis.
- Referred cases to secondary review for failure to meet criteria.
- Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
- Utilized evidence-based guidelines to support utilization review decisions and recommendations.
- Reviewed and updated utilization review criteria and guidelines to reflect current standards of practice.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
Registered Nurse, NICU
Knapp Medical Center
11.2014 - 09.2018
- Ensured safe, clean environment by adhering to infection control policies, handling equipment properly, and following waste disposal procedures.
- Reduced complications by closely monitoring vital signs, administering medications, and assessing newborns'' overall condition.
- Collaborated with multidisciplinary healthcare teams to develop individualized plans of care for premature and critically ill neonates.
- Provided compassionate end-of-life care for terminally ill neonates while offering emotional support to grieving families.
- Coordinated communication among families, physicians, therapists, social workers, dietitians, and pharmacists to foster collaborative, holistic neonatal healthcare.
- Enhanced patient care by implementing evidence-based nursing practices and protocols in the NICU setting.
- Advocated for patient rights and needs, ensuring a patient-centered approach to care delivery within the NICU setting.
Registered Nurse, NICU
Memorial Hermann Hospital System
10.2011 - 10.2014
- Managed patients with oxygen therapy including high frequency oscillatory ventilation (HFOV), inhaled nitric oxide (iNO), noninvasive mechanical ventilation (NIMV), bilevel positive airway pressure (BiPAP), continuous positive airway pressure (CPAP), and high flow nasal cannula
- Cared for neonates with congenital heart defects, meconium aspiration, extremely low birthweight, congenital anomalies, sepsis/pneumonia, feeding intolerances, withdrawal, hypoglycemia, and hyperbilirubinemia, contributing to improved patient outcomes and family education
- Administered comprehensive care for neonates with gastroschisis and omphalocele, ensuring optimal recovery and support for families
- Managed neonates with cardiac monitoring, pulse oximetry, isolettes, IV medication administration, IV infusions, PICC, arterial, Broviac and UAC/UVC lines, nasogastric/orogastric tubes
Registered Nurse, NICU
Doctors Hospital at Renaissance Health System
02.2008 - 09.2011
- Facilitated smooth transitions between hospital departments by ensuring proper handoff communication regarding patients'' ongoing infusion needs during transfers.
- Maintained detailed documentation of all aspects of IV therapy administration, including assessments, interventions, and patient responses, ensuring accurate record keeping for optimal continuity of care.
- Provided support and guidance to patients and families throughout intravenous therapies, enhancing their understanding and comfort.
- Supported efficient patient care by promptly responding to physician orders for IV therapies and coordinating with pharmacy staff.
- Reduced risk of infection by maintaining sterile environments while inserting, replacing, or removing IV lines.
- Mentored new nursing staff on best practices in IV therapy administration, promoting a collaborative and knowledgeable work environment.
- Exemplified a strong commitment to patient privacy by maintaining confidentiality of medical records and personal information in accordance with HIPAA regulations.
- Enhanced nursing skills through ongoing professional development in the field of infusion therapy, staying current with advancements in techniques and technologies.
- Promoted patient safety through strict adherence to infection control protocols during all aspects of IV insertion and maintenance.
- Enhanced patient comfort by administering IV medications and fluids with precision and care.
- Assisted physicians with bedside procedures such as central line insertions or PICC line placements, ensuring patient safety and comfort throughout.
- Educated patients on IV procedures and promptly addressed concerns, fostering increased patient satisfaction.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Monitored patient reactions after administering medications and IV therapies.
- Provided skilled, timely and level-headed emergency response to critically-ill patients.
- Quickly responded to situations impacting safety and security to unit, actualizing crisis prevention interventions to control and de-escalate situations.
Registered Nurse, NICU
Rio Grande Regional Hospital
11.2004 - 11.2008
- Enhanced patient recovery by providing specialized care for premature and critically ill newborns in high-stress NICU environment.
- Administered medications and treatments according to physician orders.
- Conducted patient assessments, recorded vitals, and analyzed records and charts to define care requirements.
- Led quality improvement projects focusing on patient safety, resulting in reduction of medication errors.
- Reduced incidence of hospital-acquired infections, adhering strictly to infection control protocols.
- Enhanced patient care by staying abreast of latest neonatal nursing research and integrating new findings into practice.
- Collaborated with multidisciplinary teams to ensure comprehensive care for neonates, resulting in holistic health improvements.
- Improved NICU's operational efficiency, organizing supplies and equipment to ensure availability and readiness.
- Provided emotional support to parents and families, offering guidance and information to navigate their NICU journey effectively.
- Guided patients, caregivers, and family members on treatment plans and local resources, strengthening support for ongoing care.
Education
Associate in Science (A.S.) - Nursing
South Texas College
Mcallen, TX05-2003
Skills
- Utilization review
- Medical necessity review
- InterQual criteria
- Clinical documentation review
- Utilization management
- Evidence-based guidelines
- Clinical judgment
- Discharge planning
- Discharge coordination
- Case coordination
- Clinical coding
- Critical thinking
- Team collaboration
- HIPAA compliance
Certification
- Registered Nurse License (RN) - State Board of Nursing.
- Basic Life Support Certification (BLS)
- CPR/AED Certification
References
Alicia Olabarrieta, Utilization Review Manager (Centene Corporation)
Tel #: (956) 778-5766
Jennifer Amador, Utilization Review Team Lead (Centene Corporation)
Tel #: (210) 717-9671
Languages
English
Timeline
Utilization Review Nurse
Centene Corporation
10.2018 - 10.2026
Registered Nurse, NICU
Knapp Medical Center
11.2014 - 09.2018
Registered Nurse, NICU
Memorial Hermann Hospital System
10.2011 - 10.2014
Registered Nurse, NICU
Doctors Hospital at Renaissance Health System
02.2008 - 09.2011
Registered Nurse, NICU
Rio Grande Regional Hospital
11.2004 - 11.2008
Associate in Science (A.S.) - Nursing
South Texas College