Ronnele Reyes

Review medical necessity for LTSS waivers, determining eligibility for personal assistance hours, personal emergency response systems, and adult daily living services not usually covered by insurance.

Provided intermittent hemodialysis, CRRT and peritoneal dialysis care using NxStage, Prismaflex, Prismax and Baxter systems and participated in a clinical trial on regional citrate anticoagulation.

Conducted prior authorization reviews for surgeries, medications and procedures applying Medicare guidelines, MCG, plan policies, radiology criteria, FDA and NCCN to determine medical necessity.

Managed resident assessments, EMR charting, nursing care plan implementation, medication administration and coordinated care with providers to ensure quality outcomes.

Performed medical necessity reviews for prior authorizations using in-house criteria, MCG and InterQual to authorize appropriate care.

Led a team of 18 USRN UM reviewers, managed escalations from clients, members and providers, and oversaw utilization review operations to ensure compliance and quality.

Provided nursing care for pediatric medical-surgical patients, including vital signs, hygiene, nutrition support and emotional support to children and families.

Completed a Bachelor of Science in Nursing at Centro Escolar University in Malolos City, Bulacan from 2010 to 2014.