Dedicated registered nurse (RN) with current experience in Case Management for the Medicaid and Medicare population. Flexible and detail oriented. Comfortable in rapidly changing medical field and willing to go the extra mile. Experience with work from home setting.
Licenses
Registered Nurse in Texas
CCM
Skill Highlights
Fluent - Bilingual Spanish/English
Flexible
Detail Oriented
High Ethical work Values
Experienced in patient Assessments
Experienced inTelephonic Case Management
Dependable
Can work Independently
Experience in EMR charts
Experience in EMR chart reviews
Experience with InterQual
Experience with Medicare/Medicaid clients
Professional Experience
11/2014 to 08/2015
RN Case Manager/Care CoordinatorBanner Health – Phoenix, AZ,
Primary role of Case Manager for Secure Horizons/Medicare Population in designated clinics and physicians' clinics.
Primary role of communicating with physicians,clients and families or Care givers to assist and improve the quality of care, assist in transitions of care from hospitals, Skilled nursing facilities to home or alternative care settings.
Facilitate navigation of medical care through the continuum of life.
Collaborate with physicians and medical team to provide care for patients.
Call clients, assess, and create individualized care plans for all clients who are in case management.
Documentation of Care Plans in EMR Charts
Notified/Updated patient's info to PCPs via EMR
Facilitate Home Health, SNF, DME for clients
2012 to 10/2014
Registered Nurse Case ManagerWoodfords Family Services – Corinna, ME,
Primary role of Case Manager for the StarPlus Medicaid population.
Calling member from generated reports to enroll in Case Management.
Experienced with Precertification process at the Medicaid Health Plan with emphasis on authorizing/reviewing requests for Home Health.
Verification of benefits, reviewed exclusions and limitations.
Interface daily with Health Care providers and physicians' offices and team in effort to provide smooth transition in delivery of health care needs.
Actively participated in development and implementation of new case management program to the StarPlus population.
Ensured assessments for clients follow up calls, and calls made to providers and physicians were properly documented.
Key Accomplishments: Assisted pre-certification Team meet time guidelines.
Responded to numerous crisis situations for demanding clients and effectively provided and gave guidance/advice/feedback regarding care maintaining respect of the clients, physicians and coworkers in a calm, levelheaded and quick thinking manner, utilizing critical thinking skills Flexible and willing to go above and beyond my role as evidenced by my continued support to the Precert Department in a time of need.
Make outbound calls to members for enrolling into Case Management Ensure follow up calls were made in timely fashion to members Update Care plans as needed - assess goals Assessments completed via telephone on new case management members.
Review Home Health orders/clinical and process/approve requests
11/2010 to 01/2012
Adult Case ManagerDavita – Columbus, OH,
Case Manager for the Chronically ill clients with emphasis on the high utilizers of Emergency encounters and readmissions.
Interfaced with clients, face to face, via telephone, in clinics and in the emergency room to provide education to clients in the disease process, medications to assist them in learning healthier skills.
Focused case management to reduce the frequency of ED and hospitalizations episodes.
Multi task- performed telephonic and in person health assessments/interviews.
Documentation skills for case management to meet NCQA guidelines.
Met with clients face to face in Emergency room setting.
12/2009 to 10/2010
Research NurseGilsbar – Covington, LA,
Worked in Research Laboratories Department-as an RN intake calls for medical complaints regarding medical drugs, Alcon surgical products and clinical documentation for medical incidents.
Handled crises calls and ensured this clinical information was entered and documented for research purposes.
Facilitated and clarified medical questions for documentation needs and ensured phone calls were returned in a timely manner.
Key Accomplishments: Effectively documented medical complaints, medical crisis for research studies.
Assessment skills and telephonic skills, daily communication with physicians, co-workers and vendors, or buyers of products.
Excellent interpersonal skills and readily establishes rapport with diverse patient population.
Flexible with Critical thinking skills.
03/2009 to 12/2009
Case Manager/Nurse ReviewerAveanna Healthcare – Cedar Rapids, IA,
Directly responsible for reviewing medical chart/electronic charts in physicians' offices /clinics for medical coding purposes.
Responding and providing direction to physicians for medical diagnosis codes/ICD9/10 codes Key Accomplishments: Daily review of medical charts capturing appropriate medical diagnosis codes.
Gained experience/knowledge in review of medical clinical information for treatment plan.
Prioritizing skills.
Assessment and Triage skills.
11/2007 to 02/2009
Case ManagerGilsbar – Covington, LA,
Clinical review nurse.
Reviewed clinical for pre-existing conditions and appropriateness of admissions.
Facilitated transfers to lower levels of care such as skilled nursing facilities or Long Term acute care facilities.
Participated in interdisciplinary team meetings.
Key Accomplishments:.
Assessment and Triage skills.
Review clinical for pre-existing conditions.
10/2005 to 11/2007
Care CoordinatorGilsbar – Covington, LA,
Responsible for utilization review for medical appropriateness of admissions and observation episodes.
Documenting in database approval of admissions and authorizations with application of InterQual criteria.
Discharge planning and setting up home health.
Screening patients for admissions to Skilled Nursing Facilities or Long Term Acute Care Facilities.
Facilitated admissions, discharges and transfers.
Participated on interdisciplinary team meetings.
Key Accomplishments: Assessment and Triage skills.
Knowledge in InterQual Criteria Knowledge of LTAC facilities Discharge planning/Admissions Coordinator for LTAC.
01/2005 to 10/2005
Case ManagerAmeriGroup Corp – City, STATE,
Case Manager for Medicaid population.
Provided education to member in their disease process, medications, how to navigate the medical systems, benefits available to them and instructed them on importance of developing a good relationship with their primary physicians or specialists.
Documentation for all patients.
Participated on interdisciplinary team for complex cases.
Assessed and processed home health request for Private Duty nursing visits and skilled nursing visits.
Performed telephonic assessments on clients for case management.
Interfaced with physicians for member's needs or concerns.
Key Accomplishments: Assessment skills and Triage Skills Telephonic skills Knowledge of Excel spreadsheets Knowledge and experience of Outlook Microsoft.
04/2001 to 01/2005
Staff ED Nurse/PreceptorHarris Methodist HEB Hospital – City, STATE,
Staff nurse in ED department.
Provided direct patient care treatment and clinical documentation for all patients in the ED department.
Handled medication administration, processed physicians' orders and all other aspects of nursing care.
Facilitated admissions, discharges and transfers; prepared chart notes and other documentation; and participated on interdisciplinary team as well as codes.
Preceptor for new ED nurses.
Translator for Spanish speaking clients for nurses and physicians.
Triage Nurse.
Key Accomplishments: Assessment skills and Triage Skills Telephonic skills Was ACLS trained.
01/2000 to 03/2001
Case ManagerPacifiCare Of Texas – City, STATE,
Case Manager for Medicare population.
Provided direct patient guidance in accessing benefits and instruction/education in disease process.
Onsite Review of hospital admissions and assisted hospital case managers in discharges planning and transfers.
Documentation of clinical utilizing the InterQual criteria and participated on interdisciplinary team meetings.
Case Manager for Spanish speaking client.
Presented Case for medical review.
Key Accomplishments:.
Assessment skills and Triage Skills.
Telephonic skills.
Education and Training
Expected in 1984
Bachelors of Science: Nursing University of Texas - El Paso, TX GPA:
BSN in Nursing Minor in Psychology
Certified Case Manager
Expected in 1984
Case Manager Certification: Nursing University of Texas at El Paso - El Paso, TX GPA:
Accomplishments
Utilization Review Experience.
Pre Authorization Experience.
Known as a patient advocate and team player; believe in empowering patients by delivering health education and nursing care that enhances wellness and quality of life.
Case Management Experience and Certified Case Manager
Experience in ED Case Manager
Bilingual in Spanish/Fluent
Experienced as Charge Nurse in Outpt Surgery
Rehabilitation Nursing Experienced
Experienced ED nurse
Languages
Bilingual Fluent in Spanish/English
Can Read, write and speak Spanish
Skills
Acute care, assess benefits, Case Manager, Case Management, Review charts, Experience CM with Chronically ill, Excellent interpersonal skills, Critical-Care Nursing, Critical thinking skills, working with Medicare clients, Medicaid clients, database entry, delivery of care/education of patients, Discharge planning, Documentation, set up Home Health, instruction to providers, patients/families,medical coding, medication administration, attend meetings, Excel spreadsheets, Outlook, assist clients in navigation of medical system/care- review/adjust care plans, Nursing, Patient Advocacy, direct patient, quality care, build quick rapport with patients/interdisciplinary teams. Research, Fluent in Spanish, Spanish speaking, telephone skills, Translator, treatment plan, Triage, Triage Skills
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