Andrew Mallo

I am an experienced Registered Nurse with a robust background in utilization review, medical necessity determination, and denial management. My career has been dedicated to conducting thorough clinical case reviews and applying approved medical necessity criteria to ensure that healthcare resources are utilized appropriately. I pride myself on my ability to collaborate effectively with healthcare teams, navigating third-party payer guidelines to support appeals processes and optimize patient care coordination while minimizing unnecessary costs.

Throughout my professional journey, I have held key roles in various organizations, including CareCentrix, Humana, and Aetna US Healthcare. In my current position as a Clinical Review Nurse, I lead denial management efforts by conducting medical necessity reviews for admissions and continued stays, ensuring compliance with payer criteria and regulatory guidelines. My efforts have significantly reduced denial rates and improved reimbursement processes, showcasing my commitment to enhancing patient care and operational efficiency.