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Manager Case

Location:
San Juan, Puerto Rico, United States
Salary:
45000.00
Posted:
November 12, 2018

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Resume:

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

TEL. 787-***-****

ac7n80@r.postjobfree.com

JESUS M. LOPEZ

Objective

Obtain a position as a Generalist Nurse, Clinical Specialist Case Manager, Utilization Review Nurse, Health Professional or similar where I can develop helping people through my knowledge and clinical experiences.

Experience

2018-actual CCN Pharmacy Pittsburg, PA

Case Manager

Evaluate assigned caseload to assure quality and effective utilization of medications. Coordinate community resource/services for patients. Initiate first Health Assesstment and anual Re-assesstments of patients regarding their specialist and non-specilist medications.

2016 – 2018 Abarca Health Rio Piedras, PR

PBM Case Manager

Review of pharmacy utilization and health management, Manage documents and participates in all processes requiring the completion of a CMR’s. Monitor medication management program (MTMP) in order to ensure that members will increase knowledge about their drug therapy and reduce adverse events, ensuring the optimal use of Pharmacotherapy.

2015 - 2016 SSS VIDA Rio Piedras, PR

Medical Claims Audit, Case Manager

Audit medical cancer claims, serve as a consultant to case analysts regarding complex medical claims.

2012-2015 Hermanos Melendez Hospital Bayamon, PR

Case Manager (Utilization Department)

Perform utilization management, utilization review, or concurrent reviews, Determine medical appropriateness of inpatient services following evaluation of medical guidelines and benefit determination, Conduct clinical chart assessments, Discuss cases with treating physicians and other healthcare professionals to better understand plans-of-care, Identify and evaluate delays in care, Initiate a discharge planning,Maintain appropriate documentation, Consult with the Medical Director as needed to troubleshoot difficult or complex cases.

2010 –2012 CVS Pharmacy Bayamon, PR

Shift Supervisor

In charge of an overnight staff, store preparation for next business day, among other.

Education

2015 – 2016 Caribbean University Bayamon, PR

MA Nurse Clinical Specialist in Gerontology with role in Administration, Institutional Programs and Education.

2011 – 2013 Caribbean University Bayamon, PR

Bachelor of Science Degree In Nursing Magna Cum Laude

1987 – 1990 National College of Business & Technology Bayamon, PR

Pharmacy Auxiliary Associate

Professional Education

RX Platform, Micromedex, ICD - 9 & 10, CPT codes, HCPS coding, Individual Claim System (RUMBA), Care Web QI & Mc Milan Medical Guides, Evolution Clinical Program, Interqual Medical Guides, Meditech Medical Program, Clinical Practice in General Medicine, Emergency Room, Pediatrics and Adult Intensive Unit, CPR Certified (exp. 2018).

Other: Protective Intervention Techniques, Business Tools for Office Administrator, Warranty Seminars, RPI, 6Sigma Project, Standard Jobs, Preventive Maintenance, Cores & Applied Failure Analysis (Part I) Training, Quality Commitment Program, AS400,. Extensive knowledge in Microsoft Word, Excel, PowerPoint, Outlook, Publisher,

Professional Achievements

Participation and achievement in the 5 point star in the PBM program of a client.

Generalist Nurse Magna Cum Laude Puerto Rico License

Decreased medical insurance claims & delays at HHM (General Medicine, Telemetry & Surgery Ward) by implementing Mc Milan Medical Guides

Decreased fraud in tools and traveling accounts by implementing procedures.

Decreased fraud in warranty and parts claims by implementing procedures.

Increased productive time and efficiency among employees.(6 Sigma & RPI)

Met and exceed Department monthly and annually sales expectations.

Best Warranty Audit in Latin American for Caterpillar Dealers (2005-2006)

Bilingual (English and Spanish)

Reference:

Furnished upon request



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