PROFESSIONAL OBJECTIVE: Experienced Registered Nurse seeking a position that

would enable me to utilize my nursing experience and clinical background allowi

ng opportunity for growth and advancement.
SUMMARY OF QUALIFICATIONS:
Strong Clinical Assessment Skills and Nursing Technical Expertise
Case Management , Home Health/ Worker Compensation Case Management
Utilization Review Experience,, Quality Assurance Experience
Clinical Documentation Medical Review Experience-
Bilingual-English/Spanish-Fluent, Computer Literate in Various Programs
Interqual & CPT Coding Experience, Strong Analytical Skills and ability to gener
ate reports
Knowledge of Medicare, IPA, Private Insurances such as SCAN, Health Net, Blue Cr
oss

PROFESSIONAL EXPERIENCE:

CCHN ,Continuity Home CareNurses, L.A. Ca

12/09 to present.
QUALITY ASSURANCE /QUALITY IMPROVEMENT MANAGER
Perform documentation review of all incoming nurse notes and evaluations and di
scharges and recertifications for a worker compensation home health agency. Inst
ruct nurses on proper documentation techniques and perform clinical audits on ch
arts. Instruct recently hired nurses on proper documentation regarding pt statu
s related to wound measurements I.V infusions /antibiotics to name a few and
perform follow up on pending reports. Generate 485 reports for initial evaluati
ons and perform chart audits for quality control. Keep updated log on infection
control and monitor patients for any infections reported. Perform also brief tra
ining sessions for new nurses during orientation and pass out handouts related t
o proper documentation for worker compensation cases.. Supervised Medical Recor
ds assistant in medical records dept and acted as resource person for inquire
s for worker comp case and policy such as Tech Health ,Blue-Cross, Blue Shield,
and other private and commercial health insurances for worker compensation case
s to ensure quality assurance for documentation requested.

Continuity HomeHealth L.A. Ca

12/09 to present
HOME HEALTH NURSE CASE MANAGER
Perform Home Health Nurse/Case Manager health case management nursing duties
for patients in their home and assess patient status and monitor patient conditi
on and recertify patients for continued home health, and perform , Oasis, wound
care, patient teaching ,discharge planning, and other nurse duties required of
home health nurse case manager. Discussed clinical status on patients status in
case conferences and submitted clinical documentation required.
NHIC-EDS-L.A.Ca. .
2/06 to 11/09
Utilization Review Analyst- Complex Medical Review
Perform medical review documentation for Medical Review for a Medicare program i
nsurance contractor to reduce payment errors by identifying and addressing billi
ng errors concerning coverage and coding for reimbursement of claims. Ensure cor
rect coding of CPT codes iutilized. Perform the process of medical review analys
is for the Center of Medicare Services. Performed medical review documentation t
o ensure medical necessity maintained for services rendered. Utilized a variety
 of software and computer programs and various research guides such as ingenix o
r CPT coding and Medicare guidelines. Performed appeals and redeterminations
for coding appeals for pending appeals for utilization review . Negotiated
rates and re pricing on codes on appeals and reviewed the clinical documentation
in order to make a determination on appeal status. Participated in case confer
ences with medical directors regarding utilization review for medical necessity
and referred complex cases to physician advisors for review and decision-making.

ISG Healthcare -L.A. .

3/03 to 5/05
Case Manager/ Workers' Compensation /Occupational Nurse
Position involved case management duties such inpatient acute care hospital stay
, coordination of all in-patient activities/out patient processes for hospitaliz
ed inpatient stay both concurrent and retrospective reviews. Performed authoriz
ation of appropriate lengths of hospitalized stay for hospital admissions, disch
arge services, and equipment and documentation for all authorized and /or denied
services for medical insurance patients. Performed discharge planning for pati
ents and coordinated home health, DME equipment and any other services necessary
for the patient upon discharge with contracted vendors and negotiated rates for
services with non-network providers. Handled Workers' Compensation case manage
ment and discussed cases with physicians and medical providers and the employer
to return injured employee to work either modified or full duty. Participated i
n case conferences with medical directors regarding utilization review for medic
al necessity and referred questionable services to physician advisors for review
and decision-making. Utilized computer systems for Workers' Compensation cases
and maintained accurate documentation.

Genex Services - Orange ,Ca. 11/00 to

2/03
Telephonic Case Manager/Workers Compensation
Position involved performing Telephonic Case Management utilizing case managemen
t services for Workers' Compensation claims in adherence to specific client stan
dards which involved contacts with all parties involved in case such as adjuster
, employer, injured worker and physician and developed care plans individualized
for each case and obtained clinical and weekly progress reports with accurate d
ocumentation. Assisted on each case for the injured worker to return to work in
a cost effective manner. Also performed utilization review for precertificati
ons and authorization request for treatment and medical necessity. Also partici
pated in monthly QA meetings and utilized resources available .

Blue Cross/WellPoint-Huntington Beach ,Ca.

8/98 -10/00 Telephon
ic Triage Nurse
Position involved assisting members of insurance plans with health/wellness prog
rams and triage assessments utilizing computer from health knowledge base via te
lephone and use of computers with accurate documentation of each triage file uti
lizing health resources available such as internet and use of Health Knowledge B
ase to assist members in various areas of outpatient treatment such as psych, ho
me health, maternity and follow up as needed.

Stat/ HRN Registry / South Coast Home Health

2/94 to 11/01
Home Health Nurse - Staff R.N.-Los Angeles, Calif
Performed registered nurse assignments that included hospital relief, clinics
,juvenile ward setting, and county clinics. Assisted in an occupational health r
esearch project and assisted doctors with exams and use of computers. Performed
home health visits and supervised LVNS & nurse aides
Dominguez Hospital-Carson, Calif.
3/88
to 12/91
Staff Nurse
Position involved performing Registered Nurse duties required in a hospital sett
ing assessing and documenting patient status, administer medications, perform I.
V. therapy and blood transfusions. I also floated to other departments such as
Oncology, Pediatrics, and Maternity.

Professional National Nurse Association of Hispanic Nurses,

Memberships
Languages Spanish, read, speak & write-fluent
References AVAILABLE UPON REQUEST.
Accreditations Case Management Society.
Education Compton College Compton, California
Associated Degree-RN program
Cal State-Los Angeles, Monterey Park, California
Bachelor Degree in Fine Arts
New York Reagent Program, New York, N,Y
Bachelor of Science in Nursing
Quality Assurance and Chart Auditing Courses-2010:
Certified Case Management Courses in Progress