Experienced RN Case Manager/Discharge Planner with recent hospital and managed care experience. Ability to combine clinical/quality consideration with regulatory/financial/utilization review demands to assure patients are receiving care in the appropriate setting and level of care. Ability to create a balance between clinical needs with efficient and cost effective utilization of resources while promoting quality outcomes. Excellent organizational skills with ability to manage multiple priorities.
California Registered Nurse License #434698- expires 10/31/18
New Mexico State RN License # R40650
Compact Texas State RN License
AHA BLS for Healthcare Providers- expires 09/2017
01/2014 to 08/2014
Care Coordinator/ Case Manager IIIMOLINA HEALTHCARE － SAN DIEGO, CA
Responsible for health care management and coordination of Molina Healthcare members with chronic and complex conditions in order to achieve optimal, clinical, financial and quality of life outcomes.
Managed a caseload of 75-80 members, mostly Spanish speaking.
Conduct assessment of member needs by collecting in-depth information from Molina information systems, the member, member's family/caregiver, hospital staff, physicians and other providers.
Promote integration of services for members including behavioral health and long term care services to enhance continuity of care.
Participated in Interdisciplinary Care Team (ICT) meetings and required training.
Maintain confidentiality and comply with HIPPA regulations.
09/2013 to Current
Case Manager II/Discharge PlannerSHARP GROSSMONT HOSPITAL － LA MESA, CA
Consistently utilize and document the six (6) essential activities of case management to include: assessment, planning, implementation, coordination, monitoring and evaluation.
Function as liaison between patients, families, payers, external case managers and interdisciplinary team, recommending appropriate modification to the plan of care to assure treatment and discharge planning objectives are met.
Collaborate with the Case Management Social Worker in facilitating referrals to local, state and federal resources and arranging patient/family counseling or support groups after discharge.
Assertively manage the inpatient cost while appropriately directing the patients movement along the continuum of care.
Partner with attending and hospital physicians to ensure appropriate utilization of resources, status classification and movement to the next level of care.
Chart reviews using the InterQual criteria.
Maintain confidentiality and comply with the Health Insurance Portability and Accountability Act (HIPPA).
Chart reviews using InterQual criteria.
11/2008 to 09/2013
RN Care Coordinator/Case ManagerUNITED HEALTHCARE COMMUNITY & STATE － ALBUQUERQUE, NM
Direct case management of at-risk aged and disabled populations in nursing facilities and local care communities.
Provide service coordination for all members receiving home and community based services.
Communicate member's needs and services to provider agencies.
Initiate interdisciplinary team meetings with member/representative to review services and ensure member's needs are being addressed.
Assist/Facilitate paperwork completion process necessary for level of care determinations via the Third Party Assessor.
Communicate and advocate for needs of members.
Educate member/representative regarding their diagnoses and UHC benefits/services.
Liaison between members and other requested UHC departmental staff.
Initiate critical incident reports when appropriate/necessary including quality of care issues.
Document all contacts with member, member's representative and providers.
Track and document enrollment, level of care, and authorizations of members.
Research and locate UHC members receiving home community based services enrolled in the UHC program.
Track, monitor and document member's preventative services.
Participate in regularly scheduled team meetings and required training.
Conduct routine chart review identifying member health changes and care needs.
01/2008 to 10/2008
Registered Nurse CASE MANAGER/DISCHARGE PLANNERMOUNTAIN VIEW REGIONAL MEDICAL CENTER － LAS CRUCES, NM
Provided clinical case management services enhancing patient-centered care.
Maximized outcomes across the continuum from admission through post-discharge.
Executed case management services, monitoring patient care.
Ensured progress toward desired outcomes, addressing patient and family needs.
Resolving obstacles to effective care.
Obtained authorization for services from third party payers.
Planned for patient discharge.
Concurrent reviews and obtain authorizations from insurance company.
02/2005 to 02/2008
CHARGE Registered NurseREHABILITATION HOSPITAL OF SOUTHERN NEW MEXICO － LAS CRUCES, NM
Night shift charge nurse.
Administered day to day operations of patient unit under direction of the Director of Nursing.
Provided professional nursing care for the comfort and well-being of patients.
Managed urgent and emergency situations.
Facilitated communication and patient care needs with inter/intra departmental staff, patients and families.
Chart review audits.
Oriented new staff, initiated in-services to nurses and patient care technicians.
Participated in Case Management assisting with new patient reviews, discharges, team conferences and referrals to other agencies.
08/2004 to 05/2005
CLINICAL Registered Nurse IIMOUNTAIN VIEW MEDICAL CENTER － Las Cruces, NM
Provided professional nursing care to post partum mothers and newborns on Post Partum Unit.
Educated mothers regarding newborns and self care, breastfeeding, etc.
Charge nurse, when scheduled.
Floated to Labor and Delivery, Medical/Surgical, ICU and ER Units, as scheduled.
11/1999 to 07/2001
SUPERVISORY REGISTERED NURSENORTH COUNTY HEALTH SERVICES － SAN MARCOS, CA
Supervised a health care team of 2 RNs, 2 LVNs, 6 Medical Assistants.
Interviewed, hired and trained new personnel.
Created and maintained weekly/monthly staff schedules.
Organized and led weekly/monthly staff meetings for entire nursing and medical staff.
Responsible for staff evaluations and assessments.
Effectively delegated assignments based on patient needs and staffing guidelines.
Ensured clinic's protocols were followed according to JCHAO, State and Federal, Medicare and Medicaid guidelines.
Supervised compliance for infection control, OSHA regulations and risk management.
Assisted with health screenings and health fairs within the clinic and community.
Conducted in-house in services, triage walk-ins, call-ins and emergencies.
Handled crisis interventions including psychiatric, social/medical referrals, pre/post HIV and STD counseling.
05/1998 to 11/1998
Clinical Registered Nurse IIPALOMAR MEDICAL CENTER － ESCONDIDO, CA
Responsible for the nursing care of two to four patients in the Step Down unit.
Provided professional nursing care per nursing protocols and MD orders, to patients on ventilators.
Started and maintained IVs, administered medications/treatments, per MD orders.
Assisted with translation services for the Spanish speaking patient/family populations.
02/1997 to 02/1998
RESEARCH Registered Nurse IIUNIVERSITY OF CALIFORNIA MEDICAL CENTER － SAN DIEGO, CA
Provided nursing care to pediatric and adult patients within UCSD's Research Unit.
Started and maintained IVs, accessed IV for blood withdrawals according to research protocols, and administered research medication.
Responsible for educating and reviewing prospective patients for new and ongoing trials.
09/1994 to 09/1997
Registered Nurse Case ManagerVNA HEALTH SERVICES － SAN DIEGO, CA
Managed the care and provision of services for 35-40 newborns, adolescent, teen and adult HIV/AIDS patients.
Implemented client care plans, assuring appropriate care.
Referred clients to health care providers, social services, community counseling and religious organizations.
Direct liaison between client and other agencies, outpatient and inpatient facilities, psychosocial services, home health agencies and hospice care.
Participated in weekly team meetings to evaluate client's progress and quality of care received.
Researched and attended community meetings in relations to client's needs.
01/1989 to 01/1994
Clinical Registered Nurse IIUNIVERSITY OF CALIFORNIA AT IRVINE MEDICAL CENTER － ORANGE, CA
Executed superior performance in multiple intensive care units (medical, surgical, CCU, post trauma, neuro, high risk OB).
Working knowledge of lines of businesses including Medicare and MediCal.
Knowledge of ICD-10, CPT and HCPC codes.
Knowledge of Allscripts and Cerner charting.
Knowledge of InterQual criteria.
Written & Verbal Spanish Fluency.
Compassionate critical thinking skills.
Strong advocate regarding HIPPA with distinct ability to support members while producing desired timely outcomes.
Ability to work independently and with team members.
Strongly respect the cultural diversity of all patients/families and co-workers.
Education and Training
Associate of Applied Science: NursingSuffolk Community College － Selden, New York
Bachelor of Science: NursingUniversity of Phoenix － Kearney Mesa, CAOngoing studying online.
Member of American Nurses Association
Member of California Nurses Association
Association of Rehabilitation Nurses
Hispanic Nurses Association
Ability to work in difficult situations and with difficult patients/families.
Advanced problem solver.
Ability to work well under stress/time line pressures.
Great people skills.
Excellent organizational skills with the ability to manage multiple priorities.