Experience

Elevance Health

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Behavioral Health Case Manager I

  • Sep 2023 - Present

  Responsible for performing case management telephonically and by ER visits within the scope of licensure for members with behavioral health and substance abuse or substance abuse disorder needs Uses appropriate screening criteria knowledge and clinical judgment to assess member needs Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment Monitors and evaluates effectiveness of care plan and modifies plan… Show more Responsible for performing case management telephonically and by ER visits within the scope of licensure for members with behavioral health and substance abuse or substance abuse disorder needs Uses appropriate screening criteria knowledge and clinical judgment to assess member needs Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment Monitors and evaluates effectiveness of care plan and modifies plan as needed Supports member access to appropriate quality and cost effective care Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers Show less Responsible for performing case management telephonically and by ER visits within the scope of licensure for members with behavioral health and substance abuse or substance abuse disorder needs Uses appropriate screening criteria knowledge and clinical judgment to assess member needs Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment Monitors and evaluates effectiveness of care plan and modifies plan… Show more Responsible for performing case management telephonically and by ER visits within the scope of licensure for members with behavioral health and substance abuse or substance abuse disorder needs Uses appropriate screening criteria knowledge and clinical judgment to assess member needs Conducts assessments to identify individual needs and develops care plan to address objectives and goals as identified during assessment Monitors and evaluates effectiveness of care plan and modifies plan as needed Supports member access to appropriate quality and cost effective care Coordinates with internal and external resources to meet identified needs of the members and collaborates with providers Show less



Gold Coast Health Plan

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Utilization Management RN/Discharge Planner

  • Mar 2022 - Nov 2023

  • Proactively identify members whose physical, mental and social circumstances present a barrier to safe hospital discharge • Assist hospital staff in facilitating timely discharge to home and/or other levels of care • Performs utilization review for all members requiring services and requiring authorization • Gather all pertinent information from providers and facilities to ensure CHP physician reviewers have sufficient information to make a decision to approve… Show more • Proactively identify members whose physical, mental and social circumstances present a barrier to safe hospital discharge • Assist hospital staff in facilitating timely discharge to home and/or other levels of care • Performs utilization review for all members requiring services and requiring authorization • Gather all pertinent information from providers and facilities to ensure CHP physician reviewers have sufficient information to make a decision to approve or deny services • Participates in clinical joint meetings with facilities/providers as needed • Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider Show less • Proactively identify members whose physical, mental and social circumstances present a barrier to safe hospital discharge • Assist hospital staff in facilitating timely discharge to home and/or other levels of care • Performs utilization review for all members requiring services and requiring authorization • Gather all pertinent information from providers and facilities to ensure CHP physician reviewers have sufficient information to make a decision to approve… Show more • Proactively identify members whose physical, mental and social circumstances present a barrier to safe hospital discharge • Assist hospital staff in facilitating timely discharge to home and/or other levels of care • Performs utilization review for all members requiring services and requiring authorization • Gather all pertinent information from providers and facilities to ensure CHP physician reviewers have sufficient information to make a decision to approve or deny services • Participates in clinical joint meetings with facilities/providers as needed • Interfaces with internal resources including Medical Directors and other Health Services staff to ensure members receive the right care at the right time in the right setting by the right provider Show less



Mitchell Genex Coventry International

• Irvine, California

• RN Field Case Manager

  • Jun 2021 - Feb 2022

  • Responsible for assessment, planning, coordination, implementation, and evaluation of injured/disabled individuals involved in the medical case management process • Work as an intermediary between carriers, attorneys, medical care providers, employers and employees • Monitor closely the progress of the injured worker and report results back to the employer and insurance carrier • Ensure appropriate and cost effective healthcare services leading to… Show more • Responsible for assessment, planning, coordination, implementation, and evaluation of injured/disabled individuals involved in the medical case management process • Work as an intermediary between carriers, attorneys, medical care providers, employers and employees • Monitor closely the progress of the injured worker and report results back to the employer and insurance carrier • Ensure appropriate and cost effective healthcare services leading to a medically rehabilitated individual who is ready to return to an optimal level of work and functioning • Using clinical skills to help coordinate the individual’s treatment program while maximizing cost containment • Serving as an intermediary to interpret and educate the individual on his/her disability and treatment plan established by the case manager, physicians, and therapists • Facilitate treatment between providers and workers Show less • Responsible for assessment, planning, coordination, implementation, and evaluation of injured/disabled individuals involved in the medical case management process • Work as an intermediary between carriers, attorneys, medical care providers, employers and employees • Monitor closely the progress of the injured worker and report results back to the employer and insurance carrier • Ensure appropriate and cost effective healthcare services leading to… Show more • Responsible for assessment, planning, coordination, implementation, and evaluation of injured/disabled individuals involved in the medical case management process • Work as an intermediary between carriers, attorneys, medical care providers, employers and employees • Monitor closely the progress of the injured worker and report results back to the employer and insurance carrier • Ensure appropriate and cost effective healthcare services leading to a medically rehabilitated individual who is ready to return to an optimal level of work and functioning • Using clinical skills to help coordinate the individual’s treatment program while maximizing cost containment • Serving as an intermediary to interpret and educate the individual on his/her disability and treatment plan established by the case manager, physicians, and therapists • Facilitate treatment between providers and workers Show less



Clinicas del Camino Real, Inc.

• United States
• Hospitals and Health Care
• 100 - 200 Employee

• Ultilization Management RN/Case Manager

  • Jan 2020 - Jun 2021

  • Conduct clinical review for service requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of medical policies, clinical guidelines, and benefit plans • Review, triage, and prioritize authorization requests to meet required turn-around times • Expedite access to appropriate care for members with urgent or immediate needs using the expedited… Show more • Conduct clinical review for service requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of medical policies, clinical guidelines, and benefit plans • Review, triage, and prioritize authorization requests to meet required turn-around times • Expedite access to appropriate care for members with urgent or immediate needs using the expedited review process • Acquire appropriate clinical records, clinical guidelines, policies • Develop determination recommendations and present cases to Medical Director for potential denial determinations or when Medical Director input is needed • Manage inpatient cases for AHP, collaborate with hospitals and skilled nursing facilities • Present inpatient cases to team with director, case managers, AHP management and medical director weekly Show less • Conduct clinical review for service requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of medical policies, clinical guidelines, and benefit plans • Review, triage, and prioritize authorization requests to meet required turn-around times • Expedite access to appropriate care for members with urgent or immediate needs using the expedited… Show more • Conduct clinical review for service requests for medical appropriateness and medical necessity using considerable clinical judgment, independent analysis, critical-thinking skills, and detailed knowledge of medical policies, clinical guidelines, and benefit plans • Review, triage, and prioritize authorization requests to meet required turn-around times • Expedite access to appropriate care for members with urgent or immediate needs using the expedited review process • Acquire appropriate clinical records, clinical guidelines, policies • Develop determination recommendations and present cases to Medical Director for potential denial determinations or when Medical Director input is needed • Manage inpatient cases for AHP, collaborate with hospitals and skilled nursing facilities • Present inpatient cases to team with director, case managers, AHP management and medical director weekly Show less



PrideStaff

• United States
• Staffing and Recruiting
• 700 & Above Employee

• Administrative Assistant

  • Apr 2019 - Dec 2019

  Worked at Tiger Capital Group, Westlake Village, California • Schedule appointments and create invoices for bidders participating in the auctions • Responsible for helping with collections and payments • Answer phone calls and provide customer service for all clients • Communicates and assists bidders with registration and troubleshooting • Import and organize items for the auction on Bidpath for the catalog • Assist with setting up landing page for the sales calendar on… Show more Worked at Tiger Capital Group, Westlake Village, California • Schedule appointments and create invoices for bidders participating in the auctions • Responsible for helping with collections and payments • Answer phone calls and provide customer service for all clients • Communicates and assists bidders with registration and troubleshooting • Import and organize items for the auction on Bidpath for the catalog • Assist with setting up landing page for the sales calendar on website • Collaborate with commercial industrial auction team and onsite supervisors from auctions • with an auction event • Assist with the marketing department regarding ways to reach out to bidders Show less Worked at Tiger Capital Group, Westlake Village, California • Schedule appointments and create invoices for bidders participating in the auctions • Responsible for helping with collections and payments • Answer phone calls and provide customer service for all clients • Communicates and assists bidders with registration and troubleshooting • Import and organize items for the auction on Bidpath for the catalog • Assist with setting up landing page for the sales calendar on… Show more Worked at Tiger Capital Group, Westlake Village, California • Schedule appointments and create invoices for bidders participating in the auctions • Responsible for helping with collections and payments • Answer phone calls and provide customer service for all clients • Communicates and assists bidders with registration and troubleshooting • Import and organize items for the auction on Bidpath for the catalog • Assist with setting up landing page for the sales calendar on website • Collaborate with commercial industrial auction team and onsite supervisors from auctions • with an auction event • Assist with the marketing department regarding ways to reach out to bidders Show less



Anthem Blue Cross and Blue Shield

• United States
• Insurance
• 700 & Above Employee

• Nurse Medical Management I

  • May 2014 - Feb 2018

  • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process for inpatient admissions and out of network services • Conducts inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts… Show more • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process for inpatient admissions and out of network services • Conducts inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts • Collaborates with providers to assess members' needs for early identification of and proactive planning for discharge planning • Communicates with Primary Medical Groups and Hospital Case Managers to collaborate about patient's admission • Responsible for out of country cases with AXA • Participates in weekly case rounds with medical directors, case managers, utilization nurses, discharge planners, manager, leads, and staff Show less • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process for inpatient admissions and out of network services • Conducts inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts… Show more • Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high quality, cost effective care throughout the medical management process for inpatient admissions and out of network services • Conducts inpatient, retrospective, out of network and appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts • Collaborates with providers to assess members' needs for early identification of and proactive planning for discharge planning • Communicates with Primary Medical Groups and Hospital Case Managers to collaborate about patient's admission • Responsible for out of country cases with AXA • Participates in weekly case rounds with medical directors, case managers, utilization nurses, discharge planners, manager, leads, and staff Show less



Kaiser Permanente

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Triage/Advice RN/Internal Medicine/Family Practice

  • Dec 2008 - May 2014

  • Performs Triage and Assesses patients both walk-ins and patients with appointments • Large Volume/Daily Phone Triage providing advice to patients per protocol, set up appointments, and message primary care physicians • Time Management Skills with managing daily duties and following up with both physicians and patients • Responsible for ordering labs, x-rays, and performing IV’s, vaccinations, injections, wound care, and back office procedures… Show more • Performs Triage and Assesses patients both walk-ins and patients with appointments • Large Volume/Daily Phone Triage providing advice to patients per protocol, set up appointments, and message primary care physicians • Time Management Skills with managing daily duties and following up with both physicians and patients • Responsible for ordering labs, x-rays, and performing IV’s, vaccinations, injections, wound care, and back office procedures • Provides educational teachings to patients • Acts as a resource for the department employees • Telephone triage assessment skills managing a large amount of calls and messages a day • Communicates with providers regarding patient care

• Advice RN/Call Center/Family Medicine

  • Jan 2002 - Dec 2008

  • Assessed and performed triage on patients with and without scheduled appointments • Responsible for administering IV’s, catherizations, injections, and other clinical procedures • Communicated directly with physicians and medical staff regarding patient care • Provided customer service to patients through messages, appointments, telephone calls, and emails • Managed Telephone Triage on Emergency and Urgent Care calls • Determined urgency to patient telephone calls and gave… Show more • Assessed and performed triage on patients with and without scheduled appointments • Responsible for administering IV’s, catherizations, injections, and other clinical procedures • Communicated directly with physicians and medical staff regarding patient care • Provided customer service to patients through messages, appointments, telephone calls, and emails • Managed Telephone Triage on Emergency and Urgent Care calls • Determined urgency to patient telephone calls and gave advice per hospital protocol • Floated as an Advice Registered Nurse to Internal Medicine at Erwin Street and Northside and to Family Medicine at Northside, Simi Valley, and Thousand Oaks



Cedars-Sinai

• United States
• Hospitals and Health Care
• 700 & Above Employee

• Cardiology RN

  • May 2001 - Nov 2001

  • Provided direct care to patients with Coronary Artery Bypass, Pre and Post-Op Heart and Heart Transplant Patients • Managed and cared for 1-5 patients daily in a 12 hour shift either alone or assisted by LVN • Provided direct care to patients with Coronary Artery Bypass, Pre and Post-Op Heart and Heart Transplant Patients • Managed and cared for 1-5 patients daily in a 12 hour shift either alone or assisted by LVN



Los Robles Hospital and Medical Center

• United States
• Hospitals and Health Care
• 500 - 600 Employee

• Oncology RN

  • Jan 2000 - Mar 2001

  • Provided direct care for patients with different stages of cancer including terminal • Treated patients in isolation rooms, epidural care, pre and post-op surgical patients, and chemotherapy patients • Performed IV insertions, blood transfusions, chest port-a-cath insertions, blood draws done through ports, groshongs, and Hickmans, and assisted doctors in bone marrow aspiration, thoracentesis, and chest tube placements • Managed and cared for 5-8 patients daily… Show more • Provided direct care for patients with different stages of cancer including terminal • Treated patients in isolation rooms, epidural care, pre and post-op surgical patients, and chemotherapy patients • Performed IV insertions, blood transfusions, chest port-a-cath insertions, blood draws done through ports, groshongs, and Hickmans, and assisted doctors in bone marrow aspiration, thoracentesis, and chest tube placements • Managed and cared for 5-8 patients daily in a 12 hour shift either alone or assisted by LVN or CNA Show less • Provided direct care for patients with different stages of cancer including terminal • Treated patients in isolation rooms, epidural care, pre and post-op surgical patients, and chemotherapy patients • Performed IV insertions, blood transfusions, chest port-a-cath insertions, blood draws done through ports, groshongs, and Hickmans, and assisted doctors in bone marrow aspiration, thoracentesis, and chest tube placements • Managed and cared for 5-8 patients daily… Show more • Provided direct care for patients with different stages of cancer including terminal • Treated patients in isolation rooms, epidural care, pre and post-op surgical patients, and chemotherapy patients • Performed IV insertions, blood transfusions, chest port-a-cath insertions, blood draws done through ports, groshongs, and Hickmans, and assisted doctors in bone marrow aspiration, thoracentesis, and chest tube placements • Managed and cared for 5-8 patients daily in a 12 hour shift either alone or assisted by LVN or CNA Show less