Oghenekome Agbawe

I support utilization management and medical-necessity decisions for health plans including Molina Healthcare, Acentra, HCSC, Aetna, and Centene. I bring Registered Nurse experience across inpatient, outpatient, behavioral health, home health, skilled nursing, and surgical reviews. At Molina Healthcare, I assessed services for outcomes, cost effectiveness, benefits, eligibility, prior authorizations, readmissions, and post-claim reviews. I also supported PEGA migration from QNXT and collaborated with multidisciplinary teams on discharge planning and care decisions. At Acentra, I reviewed 25–30 North Dakota Medicare and Medicaid cases daily, including inpatient, behavioral health, SUD, emergency, rehabilitation, and outpatient requests. I prepared cases for Medical Director review, investigated denials, supported appeals, and referred appropriate members to disease and case management. I use InterQual, MCG, GuidingCare, Atrezzo, TruCare, Meditech, SmartUM, PEGA, QNXT, and related systems to apply CMS, Medicare, Medicaid, NCQA, HEDIS, and HIPAA requirements. My bedside nursing background in progressive care also informs my clinical judgment, care coordination, and focus on safe patient transitions.