VERONICA SESE
Santa Clarita,CA
Summary
Achieved excellence in continuous assessments and clinical records oversight as a skilled utilization review nurse. Enhanced utilization review case management in an ambulatory managed care setting for over 7 years. Improved inpatient BHU case management processes for 1 year. Prepared to add value to a company that prioritizes attention to detail and clinical review proficiency. Delivered acute care through direct patient care and clinical evaluations in a hospital environment. Resolved complex, emotionally charged situations with effective problem-solving and critical thinking. Streamlined organizational tasks and prioritized responsibilities efficiently. Bilingual in English and Tagalog.
Overview
26
26
years of professional experience
1
1
Certification
Work History
Nurse Medical Management II
Elevance Health
Woodland Hills, CA
07.2021 - Current
- Conducted comprehensive reviews of medical necessity and appropriateness for patient care plans.
- Collaborated with healthcare providers to ensure compliance with established guidelines and protocols.
- Analyzed patient data to support effective utilization management decisions and resource allocation.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
- Led interdisciplinary team meetings to discuss complex cases, facilitating comprehensive care planning.
RN Care Coordinator BHU
Pacifica Hospital Of The Valley
Sun Valley, CA
08.2020 - 06.2021
- Performs medical necessity review that includes: inpatient review, concurrent review, benefits advisory/ prior authorizations, retrospective, out of network, and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, member eligibility, benefits and contracts.
- Consults with Medical Directors when care does not meet applicable criteria or medical policies.
- Documents clinical information completely, accurately, and in a timely manner.
- Meets or exceeds production and quality metrics.
- Maintains a thorough understanding of the Plan's provider contracts, member contracts, authorization requirements, and clinical criteria including Milliman Care guidelines and medical policy.
- Maintains a thorough understanding of accreditation and regulatory requirements, and ensure these requirements are followed and Utilization Management decision, determinations are within compliance.
Ambulatory Utilization Review Case Manager
Facey Medical Group
Mission Hills, CA
09.2018 - 07.2020
- Determine appropriateness and medical necessity of hospitalization and requested treatment based on healthplans guidelines, policies, Milliman, and medical director review. Applied medical criteria and clinical judgement to researched cases to evaluate and establish determination.
- Use effective relationship to management, coordination of services, resource management, education, patient advocacy and related interventions to promote cost effective medical outcomes.
- Review referrals requests from providers for medical necessity, referring to the Medical Director those that require additional expertise.
- Responsible for presenting, preparing, and submitting all recommendations for denial to the medical director and plan liaison, including arranging any peer to peer reviews, if requested by physician.
- Establish effective rapport with other employees, case managers, professional service staff and physicians.
Registered Nurse
Henry Mayo Newhall Memorial Hospital
Valencia, CA
12.2014 - 09.2018
- Provided direct patient care in medical surgical and telemetry unit to acutely ill patients.
- Administered oral, intramuscular and IV medications to patients and monitored responses.
- Monitored and recorded patient condition, vital signs, recovery progress and medication side effects.
- Coordinated care with physicians and other clinical staff to prepare for treatment, carry out interventions and enhance continuum of care to deliver comprehensive services.
- Assisted patients with healing and recovery after surgery by closely monitoring and caring for wounds, answering questions and educating about continued care strategies.
Registered Nurse, Progressive Care Unit
Antelope Valley Hospital
Lancaster, CA
03.2014 - 11.2016
Registered Nurse, Operating Room
Surgical Care Affiliates
Lancaster, CA
06.2013 - 10.2015
Registered Nurse
Beverly Hospital
Montebello, CA
10.2011 - 03.2014
Senior Insurance Claim Adjuster
Allstate Insurance Company
Woodland Hills, CA
04.2000 - 08.2005
Education
Associate of Science - Nursing
College of The Canyons
Valencia, CA12.2010
Bachelor of Science - Biology
FAR EASTERN UNIVERSITY
MANILA, PHILLIPINES03.1988
Skills
- Performed utilization reviews to optimize resource allocation and enhance patient care quality
- Performed detailed examination of records to support data-driven decision-making
- Implemented utilization management strategies to enhance operational efficiency
- Oversaw adherence to Milliman guidelines across multiple projects to enhance operational efficiency Coordinated with stakeholders to align project objectives with regulatory requirements Championed continuous improvement initiatives to optimize workflow and compliance
- Oversaw the implementation of interqual criteria to enhance patient assessment processes Collaborated with healthcare professionals to ensure adherence to clinical protocols Championed initiatives to improve quality of care through systematic evaluations
Certification
- California State Registered Nurse License, 2011 #794359
- Current BLS Certification
Timeline
Nurse Medical Management II
Elevance Health
07.2021 - Current
RN Care Coordinator BHU
Pacifica Hospital Of The Valley
08.2020 - 06.2021
Ambulatory Utilization Review Case Manager
Facey Medical Group
09.2018 - 07.2020
Registered Nurse
Henry Mayo Newhall Memorial Hospital
12.2014 - 09.2018
Registered Nurse, Progressive Care Unit
Antelope Valley Hospital
03.2014 - 11.2016
Registered Nurse, Operating Room
Surgical Care Affiliates
06.2013 - 10.2015
Registered Nurse
Beverly Hospital
10.2011 - 03.2014
Senior Insurance Claim Adjuster
Allstate Insurance Company
04.2000 - 08.2005
Associate of Science - Nursing
College of The Canyons
Bachelor of Science - Biology
FAR EASTERN UNIVERSITY