Belinda Del Toro

Utilization Review Nurse / Case Manager (Remote)

MedImpact

Jun 2024 - Jul 2025 (1 year 2 months)

• Conducted pre-authorization, concurrent, and post-service utilization reviews in alignment with URAC standards, CMS regulations, and payer medical policies. • Evaluated medical necessity for procedures, treatments, DME, and medications using MCG and InterQual clinical criteria. • Collaborated directly with Medical Directors to escalate complex determinations and coordinate peer- to-peer provider consultations. • Provided claims clinical support through comprehensive retrospective chart analysis. • Ensured compliance with HIPAA and URAC documentation requirements, maintaining audit-ready rationale for all determinations. • Coordinated with treating providers and case managers to clarify documentation insufficiencies and support coverage re

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RN Case Manager/Utilization Review

Aetna, a CVS Health Company

Jun 2024 - Dec 2024 (7 months)

• Provide extensive care coordination for members for Aetna International LOB by collaborating with different resources including PCP, SW, Specialist and other community resources and programs to address gaps in care and SDOH issues. • Telephonically assess members and evaluate member needs and requirements to achieve and/or maintain optimal wellness state • Engage members in case management as needed in multiple states and internationally. • Utilize motivational interviewing techniques to assist members in establishing achievable outcomes. • Guide members and their families toward and facilitate interaction with resources appropriate for the care and wellbeing of members • Develop care plans for members to achieve optimal health outcome •

Registered Nurse Consultant - Case Management Program Development

Scene Health

May 2024 - Current (2 years 1 month)

• Designed and refined holistic case management workflows and documentation protocols aligned with URAC, NCQA, and regulatory standards. • Delivered consultation in utilization review best practices, transitions of care, adherence outreach, and member engagement frameworks. • Developed training materials, SOPs, and workflows supporting scalable care delivery models. • Performed telehealth patient outreach to support medication adherence and care coordination with providers and pharmacy partners. • Applied motivational interviewing to promote long-term engagement and self-management outcomes.

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RN Case Manager

Zing Health

Sep 2023 - May 2024 (9 months)

• Assisted in establishing the organization's NCQA-compliant case management program. • Partnered with Medical Directors, UM teams, DME vendors, and home health agencies for complex member coordination. • Managed telephonic care plans across Medicare and Medicaid populations, emphasizing preventive health and utilization stewardship.

Team Lead/Case Manager

Devoted Health

May 2021 - Sep 2023 (2 years 5 months)

• Assist in the development of Case Management program in collaboration with others disciplines to standardize processes and protocols per NCQA standards and best practices. • Assist in developing documentation templates for charting including; assessments, care plans, and referrals • Collaborate with Program Director to establish workflows and processes for the departments Standard Operating Procedure • Present complex cases in clinical rounds to help develop an interdisciplinary plan of action for members in collaboration with medical director, social worker, UM, DME company, Home Health agency and other disciplines as needed. • Provide extensive care coordination for members by collaborating with different resources including PCP, SW, Sp

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RN Case Manager

Humana-Miramar, FL

Jan 2019 - May 2021 (2 years 5 months)

• Telephonically assess Medicaid/Medicare members and engage in case management as needed • Evaluate member needs and requirements to achieve and/or maintain optimal wellness state • Guide members and their families toward and facilitate interaction with resources appropriate for the care and wellbeing of members • Develop care plans for members to achieve optimal health outcomes • Address Heidis alerts and educate members in preventive care • Collaborate and communicate with Interdisciplinary team on member cases and outcomes • Assist in project management by creating and piloting new programs for the improvement of member care and outcomes • Assisted in process improvement to case management work flows • Lead clinical outcomes task force

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ER Nurse

HCA Healthcare-Florida

Jan 2019 - Feb 2020 (1 year 2 months)

• Develop treatment and medication plans for emergency room patients in order to set them up for a successful recovery after crisis or trauma. • Manage the room preparation for patients of all ages including pediatric patients, visiting the emergency room including sterilization of medical instruments and sanitization of surfaces before and after patient visits. • Work collaboratively with doctors and staff to provide exceptional care. • Manage multiple cases simultaneously, prioritizing needs continually. • Comply with all legal and safety requirements at all times. • Maintain accurate and up to date patient charts.

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ER Registered Nurse

Memorial Regional Hospital-Hollywood, FL

Jan 2018 - Jan 2019 (1 year 1 month)

• Develop treatment and medication plans for emergency room patients of all ages including pediatric population, in order to set them up for a successful recovery after crisis or trauma. • Manage the room preparation for patients visiting the emergency room including sterilization of medical instruments and sanitization of surfaces before and after patient visits. • Work collaboratively with doctors and staff to provide exceptional care • Perform all requested diagnostic tests • Manage multiple cases simultaneously, prioritizing needs continually • Comply with all legal and safety requirements at all times • Provide follow up care instructions to patients and make necessary referrals • Maintain accurate and up to date patient charts • Atten

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Pre-Op Nurse / Recovery Nurse

The Center for GI Disorders-Hollywood, FL

Aug 2016 - Mar 2017 (8 months)

• Assisted Physicians and Surgeons with Endoscopic Procedures • Get medical history and assess patients prior to procedure • Prepare and Recover Patients before and after Endoscopic Procedures • Educated Patients about procedures, test results, and Gl diseases • Administered Conscious Sedation Medications under Physicians guidance • Monitored patients vital signs during conscious sedation throughout their procedure • Oversee Medical Assistants and LPN in GI Suite

Hospice Case Manager RN / Telephone Triage

Vitas Healthcare

May 2016 - Oct 2018 (2 years 6 months)

• Coordinated interdisciplinary hospice service delivery and triage operations after hours. • Conducted assessments aligned with palliative care protocols and regulatory requirements. • Provided staff mentorship and workflow support as team lead.

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Case Manager RN/Telephone Triage

Vitas Healthcare - Hospice and Palliative Care-Fort Lauderdale, FL

May 2016 - Oct 2018 (2 years 6 months)

• Handle inbound/outbound calls from patients, families, and internal/external staff following prepared scripts based on call type • Assisted in process improvement to case management work flows • Provide clinical assessment and intervention utilizing the nursing process, VITAS Palliative Care Guide, and Triage Protocols. • Coordinate all service delivery after hours including patient and family education, dispatching of interdisciplinary visits using clinical prioritizing protocols and our Telecare Dispatching Protocol, and coordination of services with external vendors and resources. • Document accurately and efficiently caller information, interactions, and outcomes with patients of all ages including pediatric patients, families, contac

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