Julius Acanto
San Mateo Rizal,Philippines
Summary
Registered Nurse with 7+ years of combined hospital and utilization management experience, including Medicare prior authorization and high-volume clinical review. Experienced in applying InterQual criteria, CMS guidelines, and medical policies to support accurate and compliant coverage determinations. Handles time-sensitive cases efficiently while maintaining quality and regulatory standards. Recognized for strong clinical judgment, documentation accuracy, and effective collaboration with providers and interdisciplinary teams.
Overview
11
11
years of professional experience
2013
2013
years of post-secondary education
Work History
Pre Service Review Nurse
Optum Global Solutions
Taguig City, Philippines
07.2022 - Current
- Perform clinical coverage review of prior authorization requests to determine medical necessity based on InterQual® criteria, Medical Policies, and CMS guidelines
- Evaluate member eligibility and benefit plans to ensure requested services align with covered benefits and applicable policy requirements
- Analyze clinical documentation, including physician notes, imaging, and diagnostic results, to support accurate and compliant coverage determinations
- Coordinate with providers and internal teams to obtain additional clinical information and clarify incomplete or inconsistent documentation
- Complete timely and accurate authorization decisions while maintaining compliance with regulatory standards and organizational quality metrics
Nurse Supervisor
Padre Pio Maternity and Medical Hospital
San Mateo Rizal, Philippines
06.2016 - 11.2021
- Supervised and coordinated nursing staff across medical-surgical, pediatric, OB-GYN, and oncology units, ensuring safe and efficient patient care delivery
- Oversaw patient care activities, including admissions, treatment planning, and discharge processes, ensuring compliance with clinical standards and hospital policies
- Managed staff scheduling, workload distribution, and performance monitoring to maintain optimal unit operations
- Ensured adherence to infection control, safety protocols, and regulatory standards within the unit
- Collaborated with physicians and multidisciplinary teams to support timely clinical interventions and continuity of care
- Handled patient and family concerns, providing guidance and support to enhance patient experience and satisfaction
Staff Nurse
Padre Pio Maternity and Medical Hospital
San Mateo Rizal, Philippines
11.2014 - 06.2016
- Delivered direct patient care in medical-surgical, pediatric, OB-GYN, and oncology units, ensuring safe and evidence-based nursing practice
- Performed comprehensive patient assessments, developed care plans, and implemented appropriate nursing interventions
- Assisted in medical and surgical procedures and monitored patient responses to treatment
- Administered medications and treatments in accordance with physician orders and safety protocols
- Monitored patient condition and promptly escalated significant changes to the healthcare team
- Educated patients and families on disease management, treatment plans, and discharge instructions
- Maintained accurate and timely documentation of patient care in compliance with hospital standards
Education
Bachelor of Science - Nursing
University of the East Ramon Magsaysay Memorial Medical Center
Quezon City, PhilippinesSkills
Clinical & Utilization Management Skills
- Utilization Review & Medical Necessity Determination (InterQual, CMS, Medical Policy)
- Prior Authorization Processing (Medicare & Retirement)
- Clinical Documentation Review & Interpretation
- Regulatory Compliance & Policy Adherence (CMS, Medicare)
- Risk Identification & Escalation (urgent / at-risk cases)
Clinical Nursing Skills (Bedside)
- Comprehensive Patient Assessment & Monitoring
- Medication Administration (PO, IV, IM)
- IV Therapy & Fluid Management
- Wound Care & Infection Control
- Emergency Response & Acute Care Management
- Patient Education & Discharge Planning
Technical & Systems Skills
- Electronic Medical Records (EMR/EHR)
- Clinical Documentation Systems (eg, Doc360 or similar)
- Microsoft Office (Excel, Word, Teams)
- Case Tracking & Workflow Management Systems
Core Competencies
- Clinical Judgment & Critical Thinking
- Interdisciplinary Collaboration
- Time Management in High-Volume Settings
- Documentation Accuracy & Attention to Detail
- Adaptability in Fast-Paced Environments
Training
- InterQual® Clinical Criteria Training (CP Procedures, DME, Medicare Guidelines), Optum Global Solutions, 2025
- Advanced Cardiac Life Support (ACLS), AHA Guidelines
- U.S. Clinical Practice Updates (Metabolic, Musculoskeletal, Neurological, Respiratory), Optum Global Solutions, 2024
Professional licenses
- NCLEX-RN, Registered Nurse, State of New York Board of Nursing, 404542752
- PNLE, Registered Nurse, Professional Regulation Commission - Board of Nursing (PRC - BON), 0808765
Languages
- Tagalog
- English
References
References available upon request
Timeline
Pre Service Review Nurse
Optum Global Solutions
07.2022 - Current
Nurse Supervisor
Padre Pio Maternity and Medical Hospital
06.2016 - 11.2021
Staff Nurse
Padre Pio Maternity and Medical Hospital
11.2014 - 06.2016
Bachelor of Science - Nursing
University of the East Ramon Magsaysay Memorial Medical Center