CARMEN NEGRÓN NEGRÓN

HC-** BOX **** TRUJILLO ALTO, P.R. 00976

787-***-**** acxhpg@r.postjobfree.com

Objective:

Highly Skilled Registered Nurse (RN) and case manager with more than 16 years of experience providing superior care while ensuring smooth nursing operations and regulatory compliance.

Certifications :

Permanent RN License Certified Cannulator Expert

OSHA Training Vascular Access Coordinator

CPR Transplant Designee Training

ACLS National Incident Management System (NIMS)

Right Start Case Manager

Diabetes Specialist

Certified Hemodialysis Nurse

Certified Home Therapy Dialysis Training Program

HIPAA Law

Professional Experience:

Molina HealthCare PR San Juan- Appeals-Denials Specialist 1 (May 2016 - Sept2016)

Enters denials and requests for appeal into information system and prepares documentation for further review.

Researches issues utilizing systems and clinical assessment skills, knowledge and approved “Decision Support

Tools in the decision making process regarding health care services and care provided to members.

Assure timeliness and appropriateness of all Provider appeals according to state and federal and Molina Healthcare guidelines.

Request and obtain medical records, notes, and/or detailed bills as appropriate to assist with research.

Evaluates for medical necessity and appropriate levels of care and formulates conclusions per protocol.

Collaborates with Medical Directors and other team members to determine appropriate responses.

Obtains Medical Director’s approval for determination per Molina protocol.

Work with Customer Service to resolve balance bill issues and other member complaints regarding providers.

Prepare responses to provider grievances / appeals.

Elevates appeals to the appropriate committee and manager per protocol.

Prepares and assists in the preparation of the narratives, graphs, flowcharts, to be utilized for presentations and audits.

Coordinates workflow and interface with internal and external resources.

Receive and resolve provider inquiries related to claims.

Act as a liaison between the providers and health plan as appropriate.

Identifies and refers cases appropriately for Health Management, Case Management, Quality Improvement and Health Education per established triggers. Documents referral according to Molina Healthcare process.

Creates and/or maintains statistics and reporting.

Fresenius Medical Care Regional Office San Juan- Right Start Program Case Manager RN (2013-2015)

Provided education and care for patient, and worked closely with families during four first month in dialysis.

Maintained by means of education emotional stability and alerted interdisciplinary team about changes in patient’s conditions.

Audit Medical Record and interdisciplinary team based Medicare Regulations.

Maintain or achieve optimal levels of quality indicators and Medicare Regulations and Network 3.

Participate in meeting of quality.

Provide direct quality care to patients including daily monitoring, evaluating of medical condition, case management.

Diabetes Management and Foot Assessment.

Provide continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educate family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Management of Vascular Access, Anemia, Mineral Metabolism.

Coordinate and administer vaccines.

Coordinate appointment with Transplant Centers.

Blood sample handling.

Provided continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educated family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Developed and implement individualize Plan of Care and Comprehensive Interdisciplinary Assessment computerize documentation.

Responds to emergency situations.

Fresenius Medical Care San Juan- Staff Hemodialysis RN (2012- 2013), (2000-2009)

Providing dialysis treatment.

Maintained by means of education emotional stability and alerted interdisciplinary team about changes in patient’s conditions.

In Charge leader with 10 coworker, distribution of tasks and supervise and distribution of tasks.

Blood sample handling.

Provided continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educated family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Developed and implement individualize Plan of Care and Comprehensive Interdisciplinary Assessment computerize documentation.

Responds to emergency situations.

Fresenius Medical Care Rio Piedras – Home Therapy Dialysis Program Manager (2009- 2012)

Provide training to patient, family or caregiver of dialysis in home.

Maintained by means of education emotional stability and alerted interdisciplinary team about changes in patient’s conditions.

Management of Vascular Access

Anemia, Mineral Metabolism.

Participate in meeting of quality.

Coordinate and administer vaccines.

Coordinate appointment with Transplant Centers.

Blood sample handling.

Provided continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educated family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Developed and implement individualize Plan of Care and Comprehensive Interdisciplinary Assessment computerize documentation.

Responds to emergency situations.

Fresenius Medical Care Bayamón – Staff Hemodialysis RN (1999- 2000)

Maintained by means of education emotional stability and alerted interdisciplinary team about changes in patient’s conditions.

Blood sample handling.

Provided continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educated family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Developed and implement individualize Plan of Care and Comprehensive Interdisciplinary Assessment computerize documentation.

Responds to emergency situations.

Productos Medicos Hemodialysis Clinic – Staff Hemodialysis RN (1998-1999)

Maintained by means of education emotional stability and alerted interdisciplinary team about changes in patient’s conditions.

Blood sample handling.

Provided continuous and precise assessment of patient laboratory levels.

Coordinated care between health providers, patients, family members and ancillary services.

Educated family members on the uses, effects, and side effects of medications.

Ordered and administered medications per Doctors orders.

Communicated all pertinent information and evaluation through clear and concise documentation.

Developed and implement individualize Plan of Care and Comprehensive Interdisciplinary Assessment computerize documentation.

Responds to emergency situations.

Laboratory Mary-E Bayamón, P.R. – Staff RN (1998)

Draw blood sample and handling.

Responds to emergency situations.

Clerical Works (Secretary, Medical records,)

Assurance medical billing.

Education:

Columbia Central University, Caguas, Puerto Rico 2015

Bachelor Degree in Nursing Sciences

Metropolitan University, Rio Piedras, Puerto Rico 2009

Curse of MS Office (Word, Excel, Power Point, Access)

University of Puerto Rico, Arecibo, Puerto Rico 2007

Associate Degree in Nursing Sciences

Skills:

Fluent in Spanish/ English

Supervisor

Educator

Medical Record Audits

Leadership, Teamwork, Fast learner, Able to work with minimum supervision and under pressure

Interqual / Right Fax / MCG

Proton / E-Cube/ Acumen/ (Electronic Record)

Advance computers skills (Excel, Power Point, Microsoft Word)

Medical Electronic Data Care History and Readiness Tracking

Case Management

Concept of clinic documentation. International Classification of Disease (ICD-10)

Work in a team and independently

References: Available upon request.

Contact this candidate