Jesus Baez RN BSN
Clinical Guide: UM Nurse at Devoted Health- Claim this Profile
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English Native or bilingual proficiency
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Spanish Native or bilingual proficiency
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English Native or bilingual proficiency
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Spanish Professional working proficiency
Topline Score
Bio
Credentials
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Web Development Fundamentals
Nucamp Coding BootcampAug, 2021- Nov, 2024 -
Registered Nurse
Washington State Department of HealthJul, 2016- Nov, 2024
Experience
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Devoted Health
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United States
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Hospitals and Health Care
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700 & Above Employee
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Clinical Guide: UM Nurse
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Oct 2022 - Present
- Responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient. - Perform initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required. - Review charts for… Show more - Responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient. - Perform initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required. - Review charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients). - Coordinate care and discharge planning. Show less - Responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient. - Perform initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required. - Review charts for… Show more - Responsible for providing clinical review of cases using standard criteria to determine the medical appropriateness of inpatient. - Perform initial, concurrent, and discharge reviews of all cases, including: using medical guidelines to determine the medical appropriateness of inpatient services; assessing, interpreting, and responding to the needs or requirements of patients; identifying, escalating and resolving complex cases or issues as required. - Review charts for appropriateness and correct admission status (inpatient, observation, bedded outpatients). - Coordinate care and discharge planning. Show less
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Anthem, Inc.
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United States
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Hospitals and Health Care
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700 & Above Employee
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Nurse Medical Manager II (Utilization Management)
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Sep 2016 - Jan 2022
— Utilization Management RN for Amerigroup WA State Medicaid. — Collaborate with medical director, ancillary staff, & provider networks to review precertification request for medical necessity (DME, planned inpatient/outpatient surgery, therapy, transportation, and more). — Review of all precertification requests for medical necessity in compliance with NCQA standards of care including multiple states. — Provided training and support to RNs and ancillary staff new hires. — Subject… Show more — Utilization Management RN for Amerigroup WA State Medicaid. — Collaborate with medical director, ancillary staff, & provider networks to review precertification request for medical necessity (DME, planned inpatient/outpatient surgery, therapy, transportation, and more). — Review of all precertification requests for medical necessity in compliance with NCQA standards of care including multiple states. — Provided training and support to RNs and ancillary staff new hires. — Subject matter expert with ownership of standardization of documentation for reviews including training.
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Nurse Case Manager I - (Dual Medicaid/Medicare)
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Sep 2014 - Sep 2016
— Case Management RN for Amerigroup NY FIDA (Dual Medicaid/Medicare). — Ensures member access to services appropriate to their health needs. — Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. — Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra- contractual arrangements. — Coordinates internal and external… Show more — Case Management RN for Amerigroup NY FIDA (Dual Medicaid/Medicare). — Ensures member access to services appropriate to their health needs. — Conducts assessments to identify individual needs and a specific care management plan to address objectives and goals as identified during assessment. — Implements care plan by facilitating authorizations/referrals as appropriate within benefits structure or through extra- contractual arrangements. — Coordinates internal and external resources to meet identified needs. — Monitors and evaluates effectiveness of the care management plan and modifies as necessary. — Interfaces with Medical Directors and Physician Advisors on the development of care management treatment plans. — Assists in problem solving with providers, claims or service issues.
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Singlepoint Care Network
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Greater New York City Area
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Nurse Case Manager - Anthem Contract
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Mar 2014 - Sep 2014
- Assessed ongoing service needs and care plans of Amerigroup Managed Long Term Care members - Arranged home visits to facilitate effective service planning and implementation of services - Assessed appropriate levels of care and services for members to more accurately provide cost effective care - Collaborated with providers, caretakers, and business contractors to support member's care - Collaborated with each member to develop a plan of care detailing services being received… Show more - Assessed ongoing service needs and care plans of Amerigroup Managed Long Term Care members - Arranged home visits to facilitate effective service planning and implementation of services - Assessed appropriate levels of care and services for members to more accurately provide cost effective care - Collaborated with providers, caretakers, and business contractors to support member's care - Collaborated with each member to develop a plan of care detailing services being received and sources - Provided assistance with use of appropriate community resources as well as making referrals in accordance with business and regulatory policies and regulations of NY State. - UAS Review, Onboarding of new members, Social Work Referral Show less - Assessed ongoing service needs and care plans of Amerigroup Managed Long Term Care members - Arranged home visits to facilitate effective service planning and implementation of services - Assessed appropriate levels of care and services for members to more accurately provide cost effective care - Collaborated with providers, caretakers, and business contractors to support member's care - Collaborated with each member to develop a plan of care detailing services being received… Show more - Assessed ongoing service needs and care plans of Amerigroup Managed Long Term Care members - Arranged home visits to facilitate effective service planning and implementation of services - Assessed appropriate levels of care and services for members to more accurately provide cost effective care - Collaborated with providers, caretakers, and business contractors to support member's care - Collaborated with each member to develop a plan of care detailing services being received and sources - Provided assistance with use of appropriate community resources as well as making referrals in accordance with business and regulatory policies and regulations of NY State. - UAS Review, Onboarding of new members, Social Work Referral Show less
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East Tremont Medical Center
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Bronx, New York
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Operating Room Nurse
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Apr 2011 - Mar 2014
- Charge nurse. - Circulated/Scub (Ortho, Podiatry, Urology, Dermatology, Ophthalmology, General Surgery Cases). - Charge nurse. - Circulated/Scub (Ortho, Podiatry, Urology, Dermatology, Ophthalmology, General Surgery Cases).
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NewYork-Presbyterian Hospital
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United States
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Hospitals and Health Care
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700 & Above Employee
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Operating Room Nurse
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May 2012 - Aug 2012
- Circulated and Scrubbed in General Surgery. Temporary position. - Circulated and Scrubbed in General Surgery. Temporary position.
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Apple
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United States
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Computers and Electronics Manufacturing
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700 & Above Employee
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Specialist
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Jan 2006 - Jan 2009
- Assist customers with customizing products to fit their needs. - Provided full setup of computers, iPods, iPhones, and other Apple products. - Educated customers on features and qualities of products. - Assist customers with customizing products to fit their needs. - Provided full setup of computers, iPods, iPhones, and other Apple products. - Educated customers on features and qualities of products.
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Education
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2005 - 2010
Rutgers University - Newark
Bachelors in the Science of Nursing, Nursing -
2021 - 2022
Nucamp Coding Bootcamp
Full Stack Web and Mobile App Development
Community
