CRISTINA CASTRO DUMALI
Service Delivery Analyst / Health Clinical Services Senior Analyst
Paranaque
Summary
Experienced PHRN and USRN license holder currently serving as a clinical nurse reviewer. Skilled in analyzing medical records and ensuring compliance with healthcare regulations. Demonstrated success in providing high-quality patient care and optimizing administrative procedures.
Overview
16
16
years of professional experience
4019
4019
years of post-secondary education
Work History
Health Clinical Services Senior Analyst
Accenture Inc.
Cubao, Quezon City
02.2023 - Current
- Responsible for evaluating clinical records in accordance with medication policy to determine the medical necessity and appropriateness of medication requests.
- Cross-training of nurses from a different line of business.
- Collaborated with cross-functional teams to identify areas of improvement, leading to increased operational effectiveness.
- Nurtured strong working relationships with clients, ensuring their needs were met while exceeding expectations on deliverables.
- Analyzed data to identify root causes of problems and recommend corrective actions.
Quality Auditing Senior Analyst
Accenture Inc.
01.2021 - 02.2023
- Performs regular Quality audits based on accepted standards in sampling as agreed upon with the client to evaluate that delivery is consistent and at par with client standards.
- Analyzes data gathered from transactional audits at the agent level and the SOW level and relate its relevance to business performance metrics.
- Conducts coaching sessions with agents, as needed, tp achieve superior customer satisfaction delivery.
- Collaborates with client auditors and SMEs to confirm that processes are aligned to current business and regulatory rules.
Nurse-Clinician Services Analyst for Medicare Concurrent Review
Accenture Inc.
02.2020 - 01.2021
- Collaborates with healthcare providers/members to optimize member benefits.
- Adhere to medical policy and provide medically appropriate, high quality, cost effective service, out of network services and appropriateness of treatment setting by utilizing the applicable medical policy and industry standards.
- Pre-review screening under the guidance of US licensed health professional.
Transaction Processing Representative
Accenture Inc.
05.2011 - 01.2020
- Performs data entry and research in various systems and tracking tools.
- Apply knowledge of processes and related systems to assist in identifying, assessing and resolving issues/problems.
- Assess and resolve non-standard and standard issues or problems.
- Seek advice and escalate issues when faced with tasks/problems outside the scope of the work.
- Responsible to provide support to the clinical team and client team to assist in the promotion of quality member outcomes, to optimize member benefits, and to promote effective use of resources.
- Supports the procedures that ensure adherence to medical policy and member benefits in providing service that is medically appropriate, high quality, and cost effective.
- Gathers information and conducts pre-review screening under the guidance and direction of US licensed health professionals.
Staff nurse
Las Pinas Doctors Hospital
10.2009 - 03.2010
- Works directly with patients and their families.
- Performs frequent patient evaluations, including monitoring and tracking vital signs, performing procedures such as IV placement, phlebotomy, and administering medications.
- Develops the day-to-day nursing care plans both in hospital, and for care after discharge by families and visiting nurses.
Education
Bachelor Science - Nursing
Olivarez College
03-2007
Vocational Diploma / Short Course Certificate - Caregiving
Universal College Paranaque
Skills
- Knowledge in Utilization management process
- Call / Conversation Management
- Customer Interaction Handling
Timeline
Health Clinical Services Senior Analyst
Accenture Inc.
02.2023 - Current
Quality Auditing Senior Analyst
Accenture Inc.
01.2021 - 02.2023
Nurse-Clinician Services Analyst for Medicare Concurrent Review
Accenture Inc.
02.2020 - 01.2021
Transaction Processing Representative
Accenture Inc.
05.2011 - 01.2020
Staff nurse
Las Pinas Doctors Hospital
10.2009 - 03.2010
Bachelor Science - Nursing
Olivarez College
Vocational Diploma / Short Course Certificate - Caregiving
Universal College Paranaque
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