Manager Medical

GILBERT RAMOS, SR.

**** ******* *****, ***

Antonio, Texas 78245

(Cell)210-***-****

abgugb@r.postjobfree.com

OBJECTIVE: A highly motivated and energetic Licensed Vocational Nurse with

** ***** nursing experience, now seeking a position which will complement

background expertise in supervisory/leadership roles, case management,

managed care, health services, utilization management/review, clinical

nurse, excellent customer service and a well-respected educational mentor.

I am very enthusiastic about exploring opportunities in a career

environment to fit an employment match for success.

EDUCATION:

U.S. Army Practical Nurse Course (February 1988-April 1989)

Certification of Completion-equivalent associate nursing degree

Academy of Health Sciences Center, Fort Sam Houston, San Antonio, Texas

EXPERIENCE:

Case Manager (July 2009-June 2011)

Select Specialty Hospital, San Antonio

. Responsible for all case manager process, resourcing & communication

of patient care

. Responsible for all discharges on a 44 bed LTAC setting in a safe next

level of care

. Responsible for insurance & MCR authorization prior to admission in an

LTAC setting

. Conduct concurrent review on all patients for continued care in MCR

and insurance criteria

. Coordinate & conduct interdisciplinary team meetings to identify

outcomes & barriers

. Attend financial meetings with CEO & senior team for cost

effectiveness & patient care

Case Manager, Insurance Review (March 2008-June 2009)

Baptist Medical Center-Downtown, San Antonio

. Conducted Utilization Review on all health plans for inpatient

authorization

. Responsible for all Case Management processes, resources &

communication for safe discharges

. Maintained initial/concurrent review on all LOS patient in

Observation/Medicare 1 Day & Insurances

. Covered all levels of care in Med-Surg/Telemetry/ICU/MICU/ER-Express

Units

. Collaborated w/all Health Plans for review for authorization

. Utilized the criteria from current InterQual guidelines

Managed Care Coordinator (July 2006-February 2008)

Community First Health Plans, San Antonio

. Conducted utilization review for all UM related

authorizations/referrals from all delegated products

. Obtained authorizations from all outpatient & inpatient requested by

providers/facilities

. Help conduct Utilization Review w/Medical Director for Medical Review

on all procedures indicated

. Maintained TDI timeframe regulations for all utilization

management(UM) per URAC licensure

. Supported and assisted Case Management process, Patient Care

Committee, and QA/QI Committee

. Utilized the criteria from current InterQual guidelines website

. Covered UM/UR team as acting Supervisor in the absence of the Team

Lead/Supervisor

UT MEDICINE SAN ANTONIO Aka-UPG ( August 2000-June 2006):

Nurse Review/Supervisor (January 2006-June 2006)

Cardiology Call Center

. Responsible for the Cardiology Call Center operations for efficiency

and productivity with 2 PSR's and 1 CMA

. Conducts Cardiology consult review per InterQual criteria for patient

access and quality care (200/monthly)

1ST Level Nurse Review (March 2005-December 2005)

Specialty Referrals Management, UPG Call Center

. Responsible for CareLink consults outsourcing with Specialty referrals

by support and access issues

. Oversees entire outsourcing process, data entry, worksheets, and

disposition letters

. Collaborates with Medical Director for review, provides referral

overflow, and utilized the InterQual criteria

Health Services Specialist (August 2004-February 2005)

Utilization Management Nurse, UPG

. Responsible for all incoming Risk UM delegated referrals-Superior

CHIP/MDC

. Conducted utilization review for the Risk UM delegated plan

. Performed Patient Care Committee for medical review with Medical

Director

QA/QI Nurse Facilitator, UPG

. Conducted QM Facility site reviews

. Assisted with Quality Management issues

. Participated in QA/QI Committees for input analysis

Employee Health Coordinator, UPG

. Coordinated and conducted new Employee Orientation immunizations for

all employees

. Supported and conducted the FLU Vaccine Clinic/Drives at UPG, UHS,

and UTHSCSA sites

. Assisted with immunization ordering/logistics management

LVN-Care Coordinator (August 2000-January 2003)

Managed Care, Health Services Department, UPG

. Conducted utilization review for all Risk UM delegated health plans(12

plans)

. Obtained authorizations from all Non-Risk non-delegated HMO plans(over

20 plans)

. Maintained TDI timeframe regulations for all utilization

management(UM) per URAC licensure

. Supported and assisted Case Management process, Patient Care

Committee, and QA/QI Committee

. Utilized the criteria from Milliman and Robertson(M&R)

guidelines(2002)

*Activated Active Military Duty (January 2003-August 2004)

Platoon Sergeant, U.S. Army-Staff Sergeant (P), Texas Army National Guard

Unit: HHSC 111th ASMB, San Antonio, Texas Assignment: USA MEDDAC, Fort

Hood, Texas

. Responsible for 12-15 assigned soldiers

. Responsible for 20 contracted civilians

. Served as Assistant NCOIC of Soldier Readiness Process(SRP) Medical

Operations

. Served as NCOIC Manifest Small Pox team

. Maintained 100% accountability all equipment, personnel, and SRP OPS

sites

. Responsible for all medical stations during Pre-deployment, Post-

deployment, and Demobilization

. Responsible for processing over 3,000 soldiers per month during SRP

SKILLS:

Language-Fluent in written and verbal Spanish

Computer-MS Word, MS Excel, MS Power Point, IDXterm Pokemon and IDXterm

UHS(Winsock), Windows NT and XP, IDXtend, Clinical Inquiry Web Access, MS

Outlook, InterQual Review Manager 4.0, MS Access Specialty Referrals

Management, EMTEX, Medicare TMHP and Medicaid websites.

REFERENCES:

Available Upon Request

ADDITIONAL CREDITS:

. Currently holds an LVN licensure-expires March 2012

. A Certified Professional in Utilization Review (CPUR)-expires October

2006

. Maintained the URAC Accredited license during UM delegation

. Maintained HIPAA Compliance

. Certified Aetna-Cultural and Linguistic Enhancement of Medical

Interpreters 2005

. Assigned Evacuation Coordinator for 5th floor UPG Call Center

. Familiarized compliance for NCQA, TMHP-Medicaid, CMMS-Medicare,

CareLink program

. Retired military service: 20 years (Honorable Discharge)

OTHER POSITIONS:

LVN, Managed Care Coordinator, Humana Health Plans, Inc. (May 1999-July

2000)

LVN, Team Leader/Supervisor, FPA Gonzaba Medical Group, Inc. (June 1997-

April 1999)

LPN, Active Military Sergeant, U.S. Army (April 1989-February 1997)

. Assistant Ward Master, Medical-Surgical Ward

. Clinical Supervisor, Acute Care Clinic

. 91C/LPN-Squad Leader

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