Carlo Martinez., BA, MSW

562-***-****-cell acbats@r.postjobfree.com

Summary of Qualifications:

9+ years in the Healthcare Industry integrating, developing and

implementing HMO guidelines and protocols. Implement Dialysis

assessments and and guidelines for HMOs and Private medical Groups

(IPA)with Discharge and Utilization Review Case Management in

Mental Health

Specialties:

Community Social Services Mental Health, (IPA)Outpatient Discharge

Planning, Telephonic Chronic and Disease Management, Coordinator

of Dialysis Outpatient Clinics, CCS Medical Case Management, MDS

Charting and Compliance, HIV Care Coordination. Medicare Special

Needs Plan Programs/SPDs (SNP)underwriting Dept Assessments,

HMOs/IPA/Authorization Procedures, Utilization Hospital Case

Management, HIPAA Compliance procedures and Develop Medical Care

Plans for HMOs (IPA)using QI-7 NCQA Guidelines for Medi-

Cal/Medicare HMO

Education/Certifications:

2005 Professional Studies; Healthcare/MSW

2003 Political Science and Public Admin (BA)

Current: Certified Professional in Healthcare Management

Certification (CPHM), 02/2014

EKG Certificate •Medical Assistant, EMT and Certified Nursing

Assistant Certificate/ICU/ER/CCU Critical Care Technician •

Complex Case Management Certificate• Microsoft windows, Outlook

Microsoft Office,Telephonic Software & Call Center Services (CCS),

Trizotto Medical Records Software, Complex Case Advanced Clinical

Management (CCA)and California Medicaid Management System (CA-

MMIS) Software

Professional Experience:

10/2012- to Present Health Net/Hill Medical Group (IPA)

Case Manager/Social Worker

•Reviewed and implemented IPA-Physician's FFS payment

•Visited IPA MD's and other network providers for HMOs update

services to member's need

•Assessments in Mental Health with the elder target population

•Coordinates interventions and prevention services, including

substance abuse services, community resources and follow ups with

mental health medical care plan

•Implement Medicaid-Medical, HMOs, and authorization risk

management and procedures approval

•Review IHHSS and Meals on wheels enrollment of participants in

programs

•Implement SNP programs and assess members for Mental Health

•Refer members to outpatient Mental Health programs

•Review dialysis orders with dialysis centers

•Develop a care plan according to QI-7 guidelines and protocols in

complex case management

•Assess dialysis patients at dialysis centers

•Review (MDS) patient charting to meet current state and federal

guidelines.

•Develop Assessment and intake-Task/According to client’s needs

and apply grief and emotional understanding of personal issues for

members for support by completing a comprehensive Psychosocial

Assessment

07/2009-09/2012 Molina Healthcare Inc...

Medical Case Manager/Social Worker

•Monitored dialysis patients and hospital inpatient and review

physician’s order to determine discharge planning

•Developed dialysis assessment/intake at centers

•Developed disease education and support materials for dialysis

members

•Reviewed IHHSS and Meals on wheels enrollment of participants in

programs

•Implemened underwriting assessment

•Referred members to outpatient Mental Health programs

•Reviewed Medicare risk assessment for inpatient and outpatient

procedures

•Developed a care plan according to QI-7 guidelines and protocols

in complex case management

•Implement SNP (MDS) programs and assess the accuracy of patient

charts through compliance and reliability, in addition to making

care assessments and treatment determinations in conformity with

privacy standards and typical treatment standards and submitting

necessary information to third parties.

•Provided case management services to members with chronic or

complex conditions

•Evaluated effectiveness of the care plan and modifies as

appropriate to reach optimal outcomes.

•Measured the effectiveness of interventions to determine case

management outcomes.

•Knowledge of ICD-9, CPT coding and knowledge of SSI, Coordination

of benefits, and Third party Liability programs and integration.

•Familiarity with NCQA standards, state/federal regulations and

measurement techniques.

•Provided case management services to members with chronic or

complex conditions

11/2007-05/2009 The State California Medical Dept: County and

State DHS, and DHCS

Medi-Cal Regional Case Manager

•Reviewed, Audit medical claims in conjunction with the Appeals

dept with CPT/ICD-9 denial codes and procedures

•Developed projects for provider’s onsite visit/education and

information from phone messages into the HP eligibility system in

accordance with DHHS timelines

•Supervised and train claims cross over to accounts primarily in

the Medi-Cal field

•Reviewed claims to provide and direct third party claims handling

of accounts with large deductibles.

•Responded to providers Accreditation for Tribal, CCS, Family

Pact, Presumptive Eligibility, Rural Health Clinics (RHCs)

Federally Qualified Health Centers (FQHCs), Indian Health Services

(IHS) Medi-Cal Care Programs Accreditation procedures and

regulations

Assisted in reconciling Medicare and Medicaid remits by providing

revision of claim denials and appeal process

•Conducted and manage outcomes of various studies that may include

analyzing, reviewing, forecasting, trending, and presenting

information for strategic planning and management needs

•Analyzed, implement and duplicate patient claim denial records to

determine if clinical data must merge into CA-MMIS software system

to identify recipient ID Benefits and ineligibility

•Reviewed recipients and providers electronic medical records to

minimize identification of person’s demographics, and personal

insurance information

•Provided analytical support when compiling and reporting

information to evaluate, interpret and analyze data from Medicare,

Medi-Cal and third party payers

•EMR auditing of outpatient and inpatient hospitals, billing

records management for CPT AND ICD CODES

•Implemented volume retention control in conjunction with Medicare

and Medi-Cal Audit/Internal master file data system

05/2006-10/2007 McKesson Healthcare Solutions Los Angeles CA

Medical Case Manager--Remote (Contract)

•Developed inpatient hospital discharge planning and community

referrals.

•Developed disease management programs to decrease inpatient

hospitalizations

•Developed education and support materials for community health

workers/behavioral specialist

•Implemented Medicaid-Medical, HMOs, authorization risk management

and procedures approval

•Developed home medical equipment projects for people with

disabilities

•Taught and review telephonic EMS CRISIS calls from enrollees

•Identified projections for cost reduction and expenses to

improved services

•Ensured compliance with federal, state, and local requirements

•Supervised, educated and trained 10 to 26 medical staff

•Created admission and discharge planning assessments for the

company

•Directed regulatory compliance and medical staff credentialing

requirements.

•Developed clinical case management, discharge planning, risk

utilization control, medical records auditing, ambulatory clinical

reviews and pre-clinical authorizations from third party

insurances

10/2003-04/2006 Oasis Care Medical Group

Medical Case Manager

•Developed and managed utilization risk management for an

ambulatory Medical Group Clinic

•Assess Dialysis patients with Medical/medicare issues and apply

for the right services

•Coordinated Dialysis appointments and referrals to Neuphrologist

for any Perm Cath problems or Fistula orders

•Developed and implemented Hemo/dialysis and Peritoneal dialysis

for Spanish Speaking Patients

•Revised Hospital Inpatient dialysis orders and follow up with

outpatient dialysis clinics for appointments

•Implemented quality assurance and utilization review

•Created policy for pre-admissions screening, admissions necessity

certification, discharge planning and development of criteria for

medical care evaluation

•Developed Patient Care Coordinator Management (PCCM) for Frequent

Admission to ER

2000-2003 Memorial Healthcare(IPA)

Medical Discharge Planner

•Develop community resource network for patient’s placements

•Ensured compliance with quality patient care and regulatory

compliance

•Implemented a variety of medical utilization review risk

management with hospitals and ambulatory outpatient services

•Utilized community referral for discharges and communicate with

case management, physicians and nurses for hospital

inpatient/discharge orders

ICU/CCU/DOU/ER/Med-Surgical/OB/Pediatrics Utilization Case Manager

1998-2000 Lakewood Regional Hospital

Main Admitting/ER Dept/Medical floor Ward Clerk

•Organize and attend to patients requisitions for

outpatient/inpatient surgery and procedures and verify insurance

information

•Registered patient s for procedures and appointments

•ER admitting registration

•Med/Surgical floor caregiver

Academia Accomplishments:

2003-2005 California State University, CSUDH

Teaching Assistant

•Developed and prepared lessons for the undergraduate student in

Healthcare, Health Science

•Prepared power point lessons in blackboard

•Administered quizzes and exams in blackboard for Undergraduate

Health Science students

•Taught 300 and 500 level courses in health Science

•Participated in classes curriculum with academia professors

2005 Academia Publications: Master’s Thesis 2005

Conference Presentation

“Compton and Youth Gangs; Cultural Approach to Reduce Youth’s

Involvement. Conference Workshop in Conjunction with UCLA

References:

Carolina Lopez, LCSW. 559-***-****

Linda Murray, LCSW Hill Physician Medical Group 559-***-****

Surendra Patel MD. Surendra Internal Medical Office (559) 440-

1110

Ellen Hope Kearns, PhD, SH(ASCP) MASCP 714-***-****

Contact this candidate