Mari Santos

Registered Nurse with experience in Utilization Review and Prior Authorization. Skilled in conducting medical necessity reviews, applying Interqual/ MCG criteria, coordinating care transition and collaboration with multidisciplinary teams to optimize patient outcomes and resources utilization. Strong knowledge of payer guidelines, regulatory requirements, and documentation standards

Utilization Reviewer Nurse at Med metrix Philippines Inc (2025-05 – 2026-07)

Utilization Review Nurse

• Performed concurrent, retrospective, and prospective utilization reviews to ensure medical necessity and appropriate level of care.
• Applied InterQual and MCG criteria to support admission, continued stay, and discharge decisions.
• Evaluate patient clinical information to determine whether admission criteria support inpatient or observation status.
• Review medical records, physician documentation, diagnostic findings, and treatment plans to support level-of-care determinations.
• Refer cases that do not clearly meet established criteria for secondary review by the Physician Advisor.
• Collaborate with Case Managers, nursing staff, and attending physicians regarding recommended patient class changes when clinical criteria are not met.
• Process prior authorization requests for inpatient, outpatient, imaging, procedures, and specialty services.
• Ensure requested services meet payer coverage criteria and medical necessity requirements.
• Maintained accurate documentation in utilization management systems and EHR platforms.

Utilization Review Specialist at KMC Solutions (2024-01 – 2025-04)

Utilization Management Reviewer Nurse at Adec Innovations (2021-11 – 2023-07)

Volunteer Staff Nurse at San Jose Medical Center GMACavite (2016-05 – 2016-10)

Safety Officer/Company Nurse Supervisor at Yeonho Electronics (2010-02 – 2013-08)

Bachelor of Science in Nursing – Olivarez College (2001 – 2005)