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Lynnete Rualo

@lynneterualo

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Experienced Utilization Review Nurse with a focus on healthcare management.

United States

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What I'm looking for

I am looking for a role that allows me to leverage my nursing expertise in a dynamic healthcare environment, focusing on patient care and operational efficiency.

I am a dedicated Utilization Review Nurse with over 8 years of experience in Utilization Management and Clinical Review. My career has been marked by a commitment to ensuring quality patient care while effectively managing healthcare resources. I have worked in various capacities, including as a Senior Claims Analyst and Staff Nurse, where I honed my skills in preauthorization and claims operations.

Throughout my career, I have successfully navigated the complexities of worker’s compensation and healthcare insurance, demonstrating my ability to analyze and manage claims effectively. My educational background includes a Bachelor of Science in Nursing, which has equipped me with the clinical knowledge necessary to excel in my roles. I am passionate about improving healthcare processes and outcomes, and I continuously seek opportunities to enhance my skills and contribute to my team.

Experience

Work history, roles, and key accomplishments

Current

Utilization Review Nurse

Current

ezURs

Apr 2023 - Present (2 years 3 months)

Managed utilization review and pre-authorization processes for New York and California Worker's Compensation cases. Ensured compliance with healthcare regulations and optimized patient care pathways.

Utilization Review Healthcare Regulations

Staff Nurse

Aperion Care Wilmington IL

Apr 2021 - Mar 2023 (1 year 11 months)

Provided direct patient care in a skilled nursing and rehabilitation facility, focusing on long-term care. Collaborated with interdisciplinary teams to develop and implement patient care plans.

Patient Care Skilled Nursing Facilities Rehabilitation Long Term Care Planning

UR Assistant Manager

EXL Service Philippines, Inc.

Jan 2016 - Dec 2020 (4 years 11 months)

Oversaw utilization review operations as an Assistant Manager, ensuring efficient workflow and quality control. Conducted clinical reviews to determine the medical necessity of treatments and services.

Healthcare Operations Team Leadership

UR Clinical Reviewer

EXL Service Philippines, Inc.

Jan 2012 - Dec 2015 (3 years 11 months)

Performed clinical reviews for utilization management, assessing medical records against established criteria. Contributed to the overall efficiency of the utilization review department.

Utilization Review Medical Records Healthcare Compliance Data Analysis

Senior Claims Analyst

Accenture

Feb 2008 - Jun 2011 (3 years 4 months)

Analyzed and processed insurance claims, specializing in Worker's Compensation. Provided customer service and resolved complex claims issues.

Customer Service Insurance

Education

Degrees, certifications, and relevant coursework

University of Perpetual Help System Dalta

Bachelor of Science in Nursing, Nursing

Completed a comprehensive Bachelor of Science in Nursing program, focusing on foundational nursing principles and clinical practice. Gained essential knowledge and skills for patient care and healthcare operations.

St. Joseph's Academy

High School Diploma, General Studies

Completed high school education, building a strong academic foundation. Developed essential skills in various subjects, preparing for higher education.