Years of experience in Healthcare Utilization Management
Florencio Cruz
BSN, PHRN
Quezon City,Metro Manila
Summary
Organized Team Leader experienced in directing activities of workgroups. Develops strategies, provides training, and guide teams toward achievement of organizational goals. Strong facilitator adept at working cross-departmentally with co-management and top-level leadership. Willingness to take on added responsibilities to meet team goals.
Subject Matter Expert and trusted advisor skilled in research, analysis and examination of company technology and standard operating procedures. Interface and collaborate with clients and internal team members, providing consultative enhancement recommendations based on industry research. Improve existing processes, procedures, technical enhancements, resource requirements and stakeholder engagement procedures to align with strategic goals.
Experienced Quality Auditor with well-honed analytical skills with regulatory compliance auditing experience for 2 years. Solution-focused professional highly-regarded among peers and supervisors in Healthcare Utilization Management industry. Skilled auditor who works diligently with all levels of peers, management and external authorities.
Overview
2
2
6
6
Years of experience in Health insurance (HMO)
Work History
SME/Team Lead - Utilization Management (remote)
HURC
Short Hills, New Jersey
05.2022 - 02.2024
- Ensured daily completion of 20-25 utilization review cases per nurse.
- Enhanced overall productivity by 10% higher.
- Designed and prepared daily in-house reports including detailed findings and appropriate recommendations for 2 facilities handled.
- Trained and mentored team members, providing comprehensive onboarding support and guidance to ensure smooth integration into team.
- Developed workflow process and SOP across 14 hospitals that resulted in more streamlined process and increased efficiency. for proper review and documentation
- Cross-trained existing nurses to maximize team agility and performance.
- Built strong relationships with cross-functional teams, fostering seamless collaboration in achieving shared organizational objectives
Quality Assurance-Utilization Management (remote)
HURC
Short Hills, New Jersey
05.2022 - 02.2024
- Performed 25 quality audits per day to ensure correctness and accuracy on guidelines selected, criteria applied and recommendations provided.
- Collaborated with 4 department leads to discussing QA findings after conducting routine audits to devise corrective actions for deficiencies.
- Conducted monthly re-education measures to improve review process, increasing accuracy and efficiency of team
- Evaluated nurse's performance and provided coaching to address inefficiencies.
- Maintained quality assurance and customer satisfaction objectives across 14 hospitals handled.
Utilization Review Nurse
HURC
Short Hills, New Jersey
05.2022 - 02.2024
- - Analyzed medical records, physician orders, and other relevant documents to assess necessity and appropriateness of healthcare services starting from patient's arrival to Emergency Room to Observation/Outpatient status up to their admission as Inpatient.
- - Conducted 25-30 utilization review documentation per day through EPIC and Cerner systems to ensure that patients receive appropriate level of care and services based on established guidelines [Milliman Care Guidelines (MCG)/ InterQual criteria], medical necessity, and healthcare policies.
- - Performed clinical assessments to evaluate patient needs, identify potential gaps in care, and recommend appropriate interventions or referrals to other healthcare professionals.
- - Submitted cases for criteria failures which includes notification of attending physician and other members of health care team of inappropriate admissions, denials, end of authorized days, or other factors that have an impact on reimbursement.
- - Consulted with attending physician when documentation in medical record does not support admission or continued stay and seeks to ensure completeness of all clinical documentation.
Business Development Officer
EastWest Healthcare, Inc
Makati City, Philippines
08.2008 - 03.2014
- Educated potential customers about the benefits of various health insurance plans during seminars or one-on-one consultations.
- Attended industry conferences to stay current on market trends; utilized new knowledge gained to enhance sales approaches effectively.
- Improved client retention rates by conducting policy reviews and offering options for optimal coverage based on individual needs.
- Expanded clientele base through targeted prospecting efforts such as cold calling, networking events, and referrals from satisfied customers.
- Provided exceptional customer service, addressing concerns promptly and professionally to ensure client satisfaction.
- Increased sales by identifying client needs and recommending suitable health insurance products.
- Conducted regular follow-ups with clients to review coverage, discuss policy changes, or offer additional services as needed.
Education
Bachelor of Science - Nursing
University of Santo Tomas (UST)
España Blvd, Manila, Philippines 06.2004 - 03.2008
Skills
Utilization Review
undefinedTimeline
SME/Team Lead - Utilization Management (remote)
HURC
05.2022 - 02.2024
Quality Assurance-Utilization Management (remote)
HURC
05.2022 - 02.2024
Utilization Review Nurse
HURC
05.2022 - 02.2024
Business Development Officer
EastWest Healthcare, Inc
08.2008 - 03.2014
Bachelor of Science - Nursing
University of Santo Tomas (UST)
06.2004 - 03.2008
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