Utilization Management, Case management, Hospice and Home Health

Name: Diana Go

Address: **** ********** **,

Los Angeles CA 90042

Phone #: 818-***-****

Email: *****.****@*****.***

QUALIFICATIONS SUMMARY

An Experienced and Qualified Registered nurse who is efficient, thorough and passionate about delivering the best level of care to patients. With more than twelve years of nursing experience, currently works as Utilization Manager Nurse. With more than seven years of Utilization Reviewer nurse experience, two years of Case Management experience and with three years of hospital/clinical experience.

AREAS OF EXPERTISE

●Utilization Management Reviewer (>7 years)

●Case Management (>2 years)

●Oncology (2 years)

●Emergency Department (1 year)

EMPLOYMENT HISTORY .

UTILIZATION MANAGEMENT REVIEW RN. January 2021-Current

●Employer : MSO Medpartners/Clinicas Del Camino Real

●Short description : Assess the medical necessity, quality of care, level of care and appropriateness of health care delivery services for plan members for pre-service utilization management. Applies clinical review criteria, guidelines (Medi-cal, MCG and CMS) and screens in determining the medical necessity of health care services against the clinical data provided. Consults with physician when reviews do not meet clinical review criteria. Identify and facilitate resolution of system process problems impeding UM functions. Identify and resolve delays and obstacles as appropriate. Collaborate with physicians, UM coordinators, coding, and billing staff to answer clinical questions related to medical necessity and patient status.

RN CASE MANAGER. September 2018- December 2020

●Employer: Libertana home health

●Short description : Document assessment, case notes, care coordination, and utilization management within the Med Compass system and Devero system. Work with the participants, their legal representatives, circles of support, and primary care physicians to develop and update personalized care plans. coordinates care with interdisciplinary team associated with the participant’s needs. Conducts regular follow-ups with patients to evaluate progress, promote continuity of care and ensure improved health outcomes.

HOSPICE RN September 2018- April 2020

●Employer: New Horizons Hospice

●Short description : Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers per agency policy and procedure. Make frequent visits to the patient to evaluate their condition. Provide support and comfort according to individual patient’s need and Attends IDT meetings and coordinate care to CMT.

HOME HEALTH NURSE September 2018-February 2019

●Employer : All smiles home health

●Short description : Performs nursing assessments and develops, implements and evaluates plans of care in conjunction with the physician, patient and caregivers per agency policy and procedure. Coordinates services and scheduling with the Clinical Team Manager (CTM) and Clinical Team Coordinator (CTC) to include recommendations for additional home health care services for patients to within 24 hours of Start of Care (SOC).

QA REVIEWER. April 2018 to August 2018

●Employer : All smiles home health

●Short description : Perform chart reviews for Home Health OASIS, Star of Care (SOC), Resumptions of Care (ROC), Recertifications and Discharges to ensure documentation is complete and accurate. Collaborates with clinicians to fix any errors in the documentation in the agency's Electronic Medical Record (EMR). Facilitates or provides back up for necessary staff education identified with the chart reviews. Assists with reviews for core measures and other quality, patient safety, and customer concern projects and studies.

ONCO NURSE. April 2017 to October 2017

●Employer: Philippine General Hospital, Hospice Care Program-SHPM

●Bed capacity/Short description : The Philippine General Hospital (PGH) is a tertiary state-owned hospital administered and operated by the University of the Philippines Manila, the University of the Philippines System's Health Sciences Center. It is the largest government hospital administered by the university, and is designated as the National University Hospital. It is located at Ermita, Manila in the Philippines.

●Comprehensive Job Description : Assess and obtains patient's history and vital signs. Administered and rendered prescribed oral and intravenous medications and treatments to patients. Started, maintained, discontinued intravenous lines for administration of fluids, blood products, chemotherapeutic agents and medication

UTILIZATION MANAGEMENT REVIEWER NURSE. July 2016 to August 2017

●Employer : Cognizant Technology Solutions

●Comprehensive Job Description : Assess the medical necessity, quality of care, level of care and appropriateness of health care delivery services for plan members for pre service utilization management. Applies clinical review criteria, guidelines (Interqual & MCG care) and screens in determining the medical necessity of health care services against the clinical data provided.

Consults with physician when reviews do not meet clinical review criteria,

UTILIZATION MANAGEMENT REVIEWER NURSE. June 2012 to July 2016

●Employer : HCCA Health Connections

●Comprehensive Job Description : Process pre authorization requests, conduct initial review to determine medical necessity of elective outpatient comprehensive imaging requests, perform review activities for procedures that require preauthorization and document appropriate clinical information into the prior authorization system per company guidelines.

CLINIC ONCOLOGY NURSE. January 2011- January 2012

●Employer : Dr. Edwin Tan's Clinic

●Address :717 Medical Arts Bldg Chinese General Hospital

Blumentritt, Manila

●Comprehensive Job Description : Has been in charge of patient's schedules of appointment checkups and treatment for outpatient chemotherapy. Assist the oncologist when conducting clinical procedures i.e. preparation, monitoring and administration of patient's medications (Oral and IV chemotherapeutic drugs). Started, maintained, and discontinued intravenous lines for administration of fluids, chemotherapy agents and medications. Provided support to families and educated patients for expected chemotherapy related symptoms

ER NURSE

April 2010- April 2011

● Employer

: Philippine General Hospital, ERVP

●Comprehensive Job Description : Assists and evaluated care for at least 20 patients per shift while having total patient care responsibility for 10 patients. Extensive trauma experience i.e. vehicular accident victims & gunshot injuries.

Ambulatory and non-Ambulatory patients in the Emergency Department, Pediatric and Observation unit. Most commonly seen patients: Diabetes Mellitus, Hypertensive Cardiovascular Diseases, COPD, & Trauma. Provided support to families, educated patients & the public on various medical conditions such as: Cancer, COPD, and Cardiac diseases.

PROFESSIONAL QUALIFICATIONS

Education

Bachelor of Science in Nursing

●Centro Escolar University -Manila, Philippines (2007)

Professional License

●California Board of Nursing

License Number: 95173756

Valid Until: 05/31/2024

Certification:

●Adult CPR/AED (American Red Cross)

Valid: 07/13/2024

CHARACTER REFERENCES

Maribel Aguilar, RN

UM RN

MSO Medpartners/Clinicas del Camino Real

Mobile number 805-***-****

Cheryll Odchigue, RN

QA Nurse

Libertana Home Health

Mobile number 510-***-****

Pearly Ann Gonzaga, RN

Dialysis Nurse

Fresenius Medical Care

Mobile number 619-***-****

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