Bernadette M Senica-Bigay

**** ******* **.

San Diego, CA 92111

858-***-****

ad2g5m@r.postjobfree.com

EXPERIENCE:

-Familiar with EPIC, ECIN, INTERQUAL, MILLIMAN, EMR, CERNER, ALLSCRIPTS, CDST, EZ-CAP, HCPC, ICD-10.

-Knowledgeable with Windows 9-10. Some Vista, Microsoft Works/Word/Excel/ Outlook, some Publisher, some Powerpoint, Harvard Graphics. Some Dictation/Transcription experience. 55-60 WPM.

-Worked as a Clinical Nurse Manager/Supervisory Clinical Nurse, and Charge RN, and RN Utilization Management Specialist/Clinical Review RN. Some Public Health/Home Health RN experience - PHN cert.

-Worked as both Inpatient and Outpatient RN Utilization Review and/or RN Case Manager conducting medical necessity reviews and screening with clinical discharge planning experience for both the acute hospitals and with Managed Care Insurance plans. Reviewed case records/reports, collected and analyzed data, evaluated client's medical status and defined needs/problems to provide proactive case management services managing appropriate length of stay, and prevention of denials while following state and federal regulatory requirements.

-Implements early achievement of patient discharge planning based on either social worker or RN Case Manager assessments per facility policies. Implements attempts for early communication through clinical data to various payers to support admission, follows up and updates pt level of care, follow up and updates length of stay and authorization for post-acute services. Assures the patient is in the appropriate status and level of care based on the Medical Necessity process, and submits for Second Medical Director or Physician review per facility policy.

-Communicates and coordinates care working interdependently with the acute facility’s collaborative team of physicians / hospitalists, social workers, physical/occupational/speech therapy staff, care coordinators (LVNs), and fellow RN case managers during patient care conferences regarding current health status of the patients to be able to assess any anticipated discharge needs. Meets with patients and/or sets up patient's family conferences to provide quality case management services in an appropriate, cost-effective manner. Responsible for monitoring and re-evaluating patients daily to develop an effective discharge or appropriate rehabilitation plan while maintaining appropriate costs.

-Worked interdependently with the Ambulatory Case Management team, Complex Case Management team, Chronic Care Management Team, and Population Health Teams in order to provide coordinated, thorough and continued outpatient case management quality services to the patient after discharge from the hospital to home for follow up.

-Worked as Medical Claims Review RN responsible for review/adjudication of claims requiring med/surg and sometimes psych review as well as questionable, unusual, or special claims for contract benefits, limitations, and exclusions utilizing principles of InterQual.

-Ability to research all available resources regarding claim status and medical necessity per facility protocol or policies. Reviews, Research, and prepares cases for medical director and/or peer review when indicated. Involved with assisting the Medical Director with a project involving help with his denials and handling return calls to angry health care providers when the Medical Director was overwhelmed.

-Some RN Case Management experience assisting the Director of Case Management at an LTAC Hospital with managing discharge planning, and being challenged to deal with a variety of complex patients under Medicare, Medicaid, various Insurance programs to include Tricare, etc. Assisted with load management of complex cases while other Case Management employees were on leave or out of town.

-Worked Telemetry Floor. Adult Med/Surg/Tele background includes neuro/diabetes/urology/burn special care/trauma/wound care/gyn/ postpartum/ peritoneal dialysis/ambulatory minor surgical procedures, some ICU/SICU/PACU/CCU experience as a student RN under facility’s research pilot programs.

-Worked more than 10 years at the (DOD) Military Treatment Facilities (MTF) as an ambulatory outpatient Staff RN caring for both active duty and their dependents, includes urgent care as a triage RN, as well as Primary Care/Family Practice for patients ages newborn to 99 yrs of age. Some knowledge obtained with prior Trauma Nurse Corp Certification (TNCC) working with the military treatment facilities (MTF). Followed Triage protocols per facility policies and standards. Some knowledge of outpatient urology, diabetes, wound care, obstetrics, fertility, perinatal care through assisting the nursing officer by managing/coordinating the Prenatal Care Program. Involved with quality improvement by identifying and keeping count of Swine Flu cases among active duty patients. Also, assisted the Medical Officer at the MTF with handling all UTI cases independently using UTI protocol under a military pilot research program successfully to help all providers who are overwhelmed to help reduce their caseload. Pediatric experience in primary/family practice preventative care to include Well Baby/Child exams, Immunization update, WIC program, assisting the provider with pediatric minor outpatient surgical or diagnostic procedures. Assisted providers with outpatient procedures to include dermatology procedures, colposcopies, vasectomies, LEEP, other GYN outpatient procedures.

-Participated in Review Projects for HEDIS for both San Diego and major San Francisco based managed health plan office for continued quality management. Assisted clinicians with reviewing charts in house, as well as went out to medical offices/clinics and IPAs to obtain / review medical charts. Challenged myself to do difficult tasks for their Medical Director, QM, and Network Management for a major SF based managed health plan organization.

-Some management and administrative work for a San Francisco’s Worker’s Comp/PT clinic as an RN/Office Manager learning and dealing with UM/CM, learned bookkeeping, insurance billing, accounts receivable, deposits, familiar with and assisted non-clinical staff with ICD/HCPC coding, and difficult office tasks to include patient complaints. Challenged to supervise/assist medical assistants and physical therapy needs to provide quality patient care, as well as assisted MD with routine office procedures.

EDUCATION:

-Enrolled for Winter RN Refresher Class (CEUs/update nursing skills) - Health Occupational Center for Jan 2024

-IV Therapy and Blood Withdrawal Certification - Health Occupational Center, Santee 11/2023

-RO HEALTH– Awaiting contract RN Case Management positions. Had School Nurse Training for San Diego Unified School District in need of school RNs 1/13/23, but contract put on hold for this agency - pending 12/22-Current

-UCSD RN Refresher/Re-Entry Fall Program (CA) 10/09-12/09

-Certified Professional Utilization Review - CPUR Certification (CA) 2004

-Management Skills for First Time Supervisors (CA) 2004 Case Management- 3 units

(Problem Solving Techniques)(TX) 1997

-Utilization Management in HealthCare (Alameda, CA) 1996

-Occupational Health Nursing-3 units (Vocational Rehab for the Injured Worker) UCSD, CA 1995

-Point Loma Nazarene College (CA) Bachelor Science in Nursing (BSN) Program 1991

-Point Loma Nazarene College (CA) Public Health RN (PHN) Certification 1991 WORK HISTORY:

-Ro Health LLC Healthcare Staffing – Had School Nurse Training for SDUSD 1/13/23, but the contract was on hold or pending --- 12/22-1/23. Continuing to apply for Case Management opportunities 2023 while contract on hold.

-SCPMCS – Outpatient RN Case Manager – 4/2016 - 10/2021

-Allied Nursing Staffing Agency - Contracted with SCPMCS from 4/2016 - 9/2016

-Community Health Group- HEDIS Project-RN clinical abstractor- 2/2016 - 4/2016

(Contract with Onward HealthCare)

-UCSD Medical Center- Thornton – RN Inpatient Case Manager 11/2015 - 02/2016-Contract

-SRS Healthcare - Inpatient RN Utilization Review Case Management - 11/12- 5/15

-UNI/Preferred Nursing, Inc. (M/S, Telemetry) 5/11-12/12

-Alvarado Hospital, San Diego, CA -RN

-Paradise Valley Hospital, San Diego, CA -RN

-YOH Healthcare, LTC RN/Case Manager 7/10-8/10 Contract

-MCAS Miramar Branch Clinic, Staff RN 4/09 - 8/09

-TriWest Healthcare Alliance, San Diego, CA, UMS RN 8/04-12/08

-Spectrum Healthcare Resources = 1/00-7/04 Servicing NMCSD MTFs -

- NTC, San Diego, CA RN 8/00-3/02 & 1/03-7/04

- MCAS Miramar, CA RN Clinic Manager 4/02 - 12/02

-Tricare Outpatient Clinic, Clairemont, CA, RN 10/98-8/00

-UCSD Med Ctr, San Diego, PD RN 3/98-8/98

-ORACLE, Redwood City, Technical Business Dept- Administrative work-tech -

(Kelly Svcs) 11/97-6/98

-St Francis Worker’s Comp/PT Clinic, SF, CA, RN/Office Manager 3/97-5/97

-Staffing Home Care, SF, CA Home Health RN 9/96-12/96

-Aetna Healthcare, SF, CA, RN-HEDIS Project 12/95-2/96

-Grossmont Hospital, La Mesa, CA, RN 11/92-7/94

-Sharp Memorial Hospital, CA (MICU/CCU), Student RN Critical Care 1988-10/92

-UCSD Medical Center, CA (Pre-Registered Nurse Pilot Program

-Student RN) 1987-1991

Contact this candidate