Anabelle Garcia - Mercado

Physician and Utilization Management (UM) Reviewer with extensive experience in medical necessity determination, disability claims analysis, and utilization review across inpatient and outpatient settings. Highly skilled in interpreting complex clinical documentation, applying evidence-based criteria (InterQual/MCG), and ensuring regulatory and payer compliance. Recognized for delivering accurate, defensible clinical decisions and concise medical summaries that support timely authorization, adjudication, and appeals processes.

Utilization Management Reviewer at Regal Medical Group (2021-03 – Present)

• Perform concurrent and retrospective utilization reviews to evaluate medical necessity, appropriateness of care, and level of service.
• Apply evidence-based guidelines (InterQual/MCG) to support authorization decisions and ensure payer compliance.
• Analyze inpatient and outpatient medical records for accuracy, completeness, and regulatory adherence.
• Collaborate with interdisciplinary teams to resolve documentation gaps and strengthen clinical justification.
• Contribute to quality improvement initiatives by ensuring defensible, consistent, and timely utilization decisions.

Medical Reviewer (Contract) at CLMRS Medical Reviewer Service / PeerLink (2019-10 – 2021-03)

• Reviewed and synthesized complex medical records to determine eligibility for psychiatric disability benefits.
• Identified documentation deficiencies, inconsistencies, and coding inaccuracies impacting claims outcomes.
• Ensured compliance with payer-specific guidelines and regulatory standards.
• Produced concise, evidence-based medical summaries to support adjudication and decision-making.

Medical Reviewer / Appeals Support at Alfonso Padua (Third-Party Contractor) (2010-09 – 2013-03)

• Conducted retrospective chart reviews for insurance claims associated with major academic centers (University of Maryland Medical Center and Johns Hopkins Medical Center).
• Developed comprehensive medical summaries and appeal letters for denied claims.
• Ensured clinical accuracy, documentation integrity, and regulatory compliance.
• Supported appeals processes through structured, evidence-based medical justification.

Staff Physician | Assistant Hospital Administrator at Dr. S.B. Garcia Memorial Hospital (2008-11 – 2011-10)

• Delivered comprehensive inpatient, outpatient, and emergency medical care.
• Supervised junior clinicians and supported hospital administrative operations.
• Participated in clinical audits, ICD-10 implementation, and quality improvement initiatives.
• Assisted in optimizing workflow processes and maintaining regulatory compliance.

Doctor of Medicine in Medicine – Far Eastern University

Bachelor of Science in Nursing – St. Dominic Savio College

Bachelor of Science in Psychology – University of Santo Tomas