NANCY SOSA

**** ***** *****

San Antonio, TX **148

210-***-**** Home 210-***-**** Cell

SUMMARY OF QUALIFICATIONS:

More than 20 years in nursing in an evolving healthcare environment that spans team nursing to today’s patient-centered disease management focusing on quality care, evidence-based medicine, empowerment and education to maintain a healthy, quality of life attitude utilizing technological methods in continuum of care.

In past 20 year my extensive knowledge in CMS Regulatory standards and guidelines, Case Management, Disease Management, Critical Care, Worker’s Comp, Geriatrics, Behavioral Health, Home Health, LTSS, education, clinical and management therapies in delivering positive outcomes.

Serve as a staff resource, collaborated with nursing homes, provider agency, and other community resources to assist members obtain their medical needs, address quality management and protocol issues in support of key committees which lead the Organization in receiving continued NCQA Accreditation.

Collaborated as a committee member with other health professional organizations within the community i.e. Case Management Society of South Texas, Senior Living, and Alamo Area on aging, Alamo Breast cancer society.

Proactively Integrated data collection from a variety of sources including to but not limited to medical records, Facets, member documents to develop a safe environment and prevent readmissions with immediate update in Care Plan.

Participation in appeals, validation, review process to avoid turnover, and other projects as indicated.

Provided education to members and their families on disease process, safe home environment, and other healthcare issues thru telephonic, on-site home visits within community and surrounding geographic areas.

Followed appropriate procedures for scheduling, requesting, and reviewing records while on-site at member’s homes to prevent HIPPA violations.

Maintained a high level of quality, investigate and respond to inquiries, complaints and grievances, implemented immediate response action plan to diffuse escalation as state complaint

Knowledgeable in acute and chronic settings, Emergency, Orthopedic, Mental Health and Nursing home arena.

EDUCATION

Associate Degree in Nursing (Registered Nurse) San Antonio College San Antonio, TX

Licensed Vocational Nurse, St. Philip’s College Of Vocational Nursing

Workers Compensation Adjuster’s License

Currently working towards obtaining CCM

EMPLOYMENT

Genex Services RN medical case manager for workers comp-August 2016 to present Responsible for assessment, planning, coordination, implementation and evaluation of injured/disabled individuals involved in the medical case management process. Works as an intermediary between carriers, attorneys, medical care providers, employers and employees to ensure appropriate and cost-effective healthcare services and a medically rehabilitated individual who is ready to return to an optimal level of work and functioning.

Amerigroup/Wellpoint RN Clinical coordinator March 2011 - April 1, 2016

Was employed as a Registered nurse case manager in the LTSS department managing OCC members, responsible for all aspects of care in the Medicaid population, perform home visits to access medical, psychosocial needs to determine provider needs and or to SPW and /or other services. Coordinate with other healthcare providers, in a team effort to provide safe, cost-effective quality Care. Duties include immediate medical documentation, care plans as mandated by organization to meet NCQA and CMS guidelines.

Methodist Specialty and Transplant Hospital RN Staff nurse/Preceptor September 2006-March 2011

While employed as RN Staff Nurse, my employment involved working with elderly Geriatric population, duties included to manage all aspect of nursing care to include assessment, medications, education, discharge planning and intravenous infusion therapy to provide quality cost-effective care. Promoted to Team Leader supervised all clinical staff, LVN’s, aides and unit clerks Serves as preceptor for new nurses on unit.

Genex Services RN Nurse Medical Case Manager for workers compensation September 2005- August 2006

As the Lead Clinical Case Manager for Genex workers compensation organization, my duties were to developed integration of cost-containment services that encompass medical utilization review, medical case management, quality programs, medical bill analysis, return to work programs and evidence based guidelines for San Antonio, Austin, Corpus Christi and Market. My role and responsibilities included to be knowledgeable on Workers’ compensation rules and regulations in dealing with catastrophic, psychiatric, and long-term planning.

A Plus Home Health RN Case Manager May 2002 - August 2005

As a Field RN Case Manager was responsible for management of the elderly homebound Medicare population, with complex co-morbid conditions to include psychiatric, chronic diabetes, hypertension, HIV, COPD and other complex medical conditions. Responsible for documentation, meet CMS regulatory guidelines within timely turnaround time. My assignment included traveling through the San Antonio and outlying geographic areas to meet patient’s needs.

San Antonio State Hospital RN Supervisor November 1998 - May 2002

While employed As the RN Staff Nurse I was responsible for daily management of psychiatric patients in different psychiatric specialties. Ensured a safe, environment while maintaining quality nursing needs to improve care and be able to transition to safe home setting. Supervised 3 units and did yearly evaluations on 20 staff.

San Antonio State School, Outreach Services RN Case Manager July 1995 - May 2002

Employed as RN Dual Diagnosis patients in the community and to educate, identify medical needs in the workplace. Responsible and assisted in initiating the first HCS Program at the facility. Case managed their care so all needs were met.