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Merlande
MERLANDE2001@YAHOO.COM
305-794-1365
2888 SW 83rd AVE
Hollywood, FL 33025
Remote Utilization Management Inpatient Nurse Reviewer
10 years experience W2
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Summary

  • Utilization Manager with 8 years of experience.
  • Receives review requests and conducts in network/out of network initial medical necessity clinical screening utilizing CMS National Coverage Determinations/Local Coverage Determinations.
  • Abstract clinical data from medical review for HEDIS measures and analysis of medical chart as outline by NCQA.
  • Strong knowledge of medical record abstraction, clinical reviews and regulatory requirements.
  • Determines if initial clinical information presented meets medical necessity criteria or requires additional medical necessity review, abstracts clinical case/potential denials and escalates to Medical Directors as required.
  • Current and active FL Compact Registered Nurse Licensure.

Experience
Edit Skills
Non-cloudteam Skill
Education
Bachelor's in Nursing
University of Miami
Certifications
Florida Compact RN License
Skills
Nursing
2023
8
Utilization Review
2023
5
Registered Nurse
2018
4
HEDIS
2021
3
Medical Records
2021
3
Project Management
2023
3
Medical Review
2018
2
National Committee for Quality Assurance
2018
2
Orthopedic
2015
2
Post-op
2016
2
Surgical Nursing
2015
2
Vendor Management
2018
2
Clinical Review
2023
1
JIVA
2023
1
Pediatric
2019
1
Training
2023
1
Utilization Management
2023
1
Compliance
2016
1
Pre-op
2016
1
Project Assistant
2016
1