LVN
Resume:
Rosemarie Sanchez, LVN
San Antonio, TX 78214
Email address: ad2ppp@r.postjobfree.com
Professional Experience
Company
Superior HealthPlan, San Antonio TX
Title
Senior Trainer
Timeframe
Nov 2018- current
Description
Coordinate training efforts with various cross-functional areas
Develop and administer a universal training curriculum, employ technologies and enhance training development programs
Develop teaching aids such as training handbooks, demonstration models, multimedia visual aids, computer tutorials, and reference works
Evaluate effectiveness of training programs, including cost and benefits analyses and communicate results to management
Audit team results, identify gaps in training and implement improvements in training programs
Star Plus/Star Kids/Star Health/MMP Experience
Review and recommend updates to policies and procedures
Travel to Train in various locations throughout TX (10%), Virtual Training via Zoom/Teams
Conducted Monthly Webinars- Star Plus Product
Company
Superior HealthPlan, San Antonio TX
Title
Concurrent Review Nurse- Discharge Planning
Timeframe
July 2017- Nov 2018 (position taken away due to restructuring, No LVN)
Description
Review IP clinical information and utilize InterQual for IP approval of authorization
Developed and trained Discharge Planning process to staff
Send IP reviews not meeting InterQual criteria to Medical Director for review
Ensure follow up review of IP cases are completed within TAT
Maintain a caseload of 25 cases for review daily
Knowledge of Concurrent review cases for all plans except FosterCare
Assist IP facilities with Discharge Planning for all plans except Foster Care
Assistance with finding par providers for HH, DME, transfers, etc.
Assist with SCA for Ambetter team- make contact with providers
Follow Discharge Planning cases until member has Discharged home and/or transferred for all plans except MMP/FosterCare
Assist IP facilities with benefit questions as needed (research)
Company
Superior HealthPlan, San Antonio TX
Title
Manager, Medicare-Medicaid (MMP) Shared Service (Concurrent Review/Transition of Care)
Timeframe
September 2016 to July 2017 (position taken away due to restructuring, No LVN)
Description
Oversight of Inpatient Authorization team, Concurrent Review Nurses, and the Transition of Care Team- to ensure care coordination is completed for members transition post discharge, review of audits, quality and performance
Developed and trained Transition of Care team process
Coordinated Inpatient rounds to ensure collaboration of Behavioral Health, Nurtur, Pharmacy, Medical Directors and Service Coordination teams resulting in a 6% decrease in IP readmissions
Developed training material and work processes to ensure alignment with compliance and Medicare regulations-NCQA/HEDIS
Analyzed reports to track compliance with required turn-around-times, to measure productivity, quality and identify/remedy gaps in process
Conducted adhoc audits of member medical charts to ensure accuracy of nursing documentation and closure of medical gaps for complete care coordination
Business Health Plan Liaison for the Centralized Medicare Unit housed in Florida to address any Medicare authorization related issues
Responsible for research and resolution of claim issues related to inpatient authorizations as identified in our internal claims system report
Implemented a proactive approach process to increase connectivity rate while member is inpatient in combination to the required post discharge outreaches, resulting in improvement from non-compliant to current 93% compliance
Company
Superior HealthPlan, San Antonio TX
Title
Manager, Medicare-Medicaid (MMP) Shared Service (Intake/Scheduling/Member Connections)
Timeframe
April 2016 – August 2016 (Position taken away due to restructuring, No LVN)
Description
Responsible for the coordination and timeliness of scheduled face-to-face assessments for entire MMP membership
Assist with enrollment issues and updates
Developed and trained staff on the Transition of Care process
Point of contact with the Health and Human Services Commission (HHSC) and the Plan Support Unit (PSU) within Intake department for all assessment transactions
Aligned required annual reassessments in conjunction with members expiring LTSS authorizations, Individual Service Plans (ISP), and change in conditions
Achieved a 98% compliance rating for timeliness of Upgrade submissions to HHSC
Oversight of Member Connections staff that target gaps in care for high utilizers of ER visits to promote ED diversion
Company
Superior HealthPlan, San Antonio TX
Title
Manager, MMP Service Coordination
Timeframe
May 2015- March 2016
Description
Oversight of 20+ field nurse service coordinators for the Bexar County region
Analyzed multiple reports to determine that necessary face to face visits, annual telephonic outreaches, and Health Risk reassessments were completed with required timeframes
Conducted adhoc audits of member medical charts to ensure accuracy of nursing documentation and closure of medical gaps for complete care coordination
Ensured compliance with required 10-day service coordination post discharge follow-up outreach
Completed staff one-to-one monthly meeting and annual performance reviews
Company
Superior HealthPlan, San Antonio TX
Title
Service Coordination Supervisor, Star+Plus TOC Team
Timeframe
Feb 2014-May 2015
Description
Transition of Care team- impletion of Outreach to members for ER, Pre and Post Discharge assessments
Review of reports to ensure metrics are met for NCQA requirements
Review of audits and quality results
Review of Authorizations and/or corrections needed
Follow up with staff to ensure all medical needs are met for members to prevent additional ER and/or IP visits
Follow up, review and distribution of work for clinical and non-clinical staff
Review of medical charts to ensure nursing documentation is correct and outreach attempts to our members are met and within compliance guidelines
Assist with escalated issues and assist with member issues such as 2060 scheduling, DME, placement, pharmacy and physician appointments, etc. as needed.
Create documentation guidelines for staff as resource and trained staff
Company
Superior Health Plans, San Antonio TX
Title
Services Coordinator, Foster Care
Timeframe
Jun 2013-Feb 2014
Description
Identify special needs members through the completion of health screens and other resources
Work with community outreach/member advocates to coordinate member care.
Educate PCP’s, members, medical consenters, and caregivers on behavioral health issues including symptoms, relapse prevention, stress reduction and healthy lifestyle choices
Educate members with special needs to foster compliance with program and positively impact outcomes
Conduct telephonic assessments following discharge from hospital to determine medical needs for child
PAS review/authorization entry
Scan calls with CPS for member updates
Coordination of Care with BH, Nurtur, PCP and CPS when and if needed
Company
Methodist Hospital, San Antonio TX
Title
Payor Liaison
Description
verification for inpatient/outpatient requirements MCO/Medicaid/Medicare
communication with insurance Case Management concurrent review for authorizations and discussion of clinical information
InterQual entry / review to ensure IP hospitalization criteria is met
Medicare verification for IP/OBS requirements, within Medicare guidelines
telephonic orders to change admission status when and if necessary,
clinical review via Meditech/charts to ensure clinical information is submitted to insurance company to determine medical necessity
Company
United HealthCare
Title
Claims Supervisor / Customer Service Supervisor/ Provider Services/Provider Relations
Description
Oversight for Claims payments, Coordination or Benefits and Reconciliation
Commercial plans for HMO/PPO and worked with Tricare, Medicare and Medicaid
Review of claims to ensure proper claims CPT coding and diagnosis coding
review of Authorizations for inpatient and outpatient, provider type verification for charges billed
Weekly quality claims audits for each staff member on team to ensure correct claim payments made
Provider contract documentation to ensure contract completed
Negotiate provider rates when and if needed
Handled provider escalated calls as well as Member calls
Trained staff on process changes and updates
Audits for member/provider calls to ensure quality standards were met
Implement claims payment per Medicare guidelines
Monthly/Annual reviews for staff (up to 21 employees) to ensure goals are met as required and plan for improvement, corrective action when and if necessary
Oversight for Claims payments and Coordination or Benefits
Commercial plans for HMO/PPO and worked with Tricare, Medicare and Medicaid
Review of claims to ensure proper claims CPT coding and diagnosis coding
review of Authorizations for inpatient and outpatient, provider type verification for charges billed
Weekly quality claims audits for each staff member on team to ensure correct claim payments made
Handled provider escalated calls as well as Member calls
Spoke to providers regarding contract information
Audits for member/provider calls to ensure quality standards were met
Implement claims payment per Medicare guidelines
Monthly/Annual reviews for staff (up to 21 employees) to ensure goals are met as required and plan for improvement, corrective action when and if necessary
Education/Licensure
Graduate Galen College of Nursing LVN, 2012
Harlandale High School, San Antonio, TX
Application/Plan Information
Star Health, Star+Plus, Medicare, Medicaid, Commercial Plans, Ambetter (Market Place), TruCare, Amisys, ImpactPro, Intrepreta, memberCENter-Web, Articulate, Camastia, PowerPoint, Excel, Microsoft Word, Outlook, OneNote, InterQual, Zoom, Uptivity, Kahoot, OMNI, NICE Engage, CVS
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