Andrew Mallo
@andrewmallo
Experienced Registered Nurse specializing in clinical review and utilization management.
What I'm looking for
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.
Experience
Work history, roles, and key accomplishments
Clinical Review Nurse
CareCentrix
Jun 2013 - Present (12 years 1 month)
Conducts medical necessity reviews for admissions and continued stay, ensuring compliance with payer criteria and regulatory guidelines. Utilizes approved clinical review criteria to determine appropriate patient status and resource utilization.
Utilization Review Nurse
Humana
Apr 2010 - Present (15 years 3 months)
Performed clinical reviews of inpatient admissions, verifying adherence to medical necessity guidelines. Supported appeal and reconsideration processes by gathering clinical evidence and presenting case rationales.
Clinical Reviewer
Aetna US Healthcare
May 2007 - Present (18 years 2 months)
Evaluated hospital admissions and treatment plans to determine coverage eligibility. Assisted with payer audits, appeals, and medical necessity reviews.
Education
Degrees, certifications, and relevant coursework
Florida International University
Bachelor of Science in Nursing, Nursing
Completed a comprehensive curriculum focused on nursing principles, patient care, and healthcare systems. Gained foundational knowledge and practical skills essential for a career in nursing.
Tech stack
Software and tools used professionally
Availability
Location
Authorized to work in
Job categories
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