Registered Nurse Case Manager
Resume:
Sylvia A. Gyimesi
Registered Nurse / Case Manager
Hemet, California
92544
California Registered Nures License – Active
EXPERIENCE
July 1, 2022 – Present retired
Home was destroyed in the Hemet, CA Fairview Fire. Time spent getting property in order.
At this time looking for a part time job that is remote. 2007 – July 1, 2022
HeatlhNet of California
San Bernardino, California
Care Manager
Work from home
2007- 2011: Prior Athorization Department Reveiwed medical requests for procedures, equipment surgeries Etc., applied plan policies and government regulations (reviewed Commercial- HMO, PPO, etc, Medicare, Medi-Cal)
Documented and referred cases appropriately for Medical Director review as needed 2011 – Current: Denial Compliance Unit composing and ensuring grade level and compliance standards and regulatory standards are included. Ensures reference material for denial of services is included. Letters for all Insurance types: Commercial, PPO, Indemnity, Medicare, MediCal/Caid. Whatever line of business company has. Developed templates for letters to ensure consistency in letter composition. Identified areas of concern with solutions.
2005 – 2007
Inland Empire Health Plan (IEHP)
San Bernardino, California
Care Manager
Coordinated the medical care and treatment of IEHP Direct members. Interacted telephonically with the members to assist them in obtaining needed care in a timely manner.
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Sylvia A. Gyimesi
Registered Nurse / Case Manager
Visited members at off site facilities as indicated by the need of the case. Accessed various computer databases to coordinate the activities for the members and ensure that contracted providers were utilized. When necessary assist with the coordination of letters of agreement for services needed by members. Documented all activities in the case management database. Worked closely with various departments to ensure the continuity of care and access for members.
2003 – 2005
Senior Care Action Network (SCAN)
Long Beach, California
Coordinated the medical care and treatment of SCAN members. Interacted telephonically with the medical groups for the members and members to assist them in obtaining needed care in a timely manner.
Visited members at off site facilities as indicated by the need of the case. Accessed various computer databases to coordinate the activities for the medical groups and members to ensure that contracted providers were utilized. When necessary assist with the coordination of letters of agreement for services needed by members. Documented all activities in the case management database. Worked closely with various departments to ensure the continuity of care and access for members.
2002 -2003
PacifiCare
Manager Appeals and Grievances
Provided oversight of the appeals and grievances for expedited appeals, pharmacy appeals and the PPO product.
Reviewed cases as appropriate to resolve discrepancies and concerns from members. Ensure that compliance standards were met, while also ensuring that cases were managed appropriately.
Provide supervision of the appeals and grievance staff including evaluations, discipline, etc.
1991 -2001
Kaiser Permanente
Director Case Coordination Center
Pasadena, California
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Sylvia A. Gyimesi
Registered Nurse / Case Manager
Developed a small call center of 6 employees to an operation of 3 call centers and 100 plus employees. Saving the organization hundreds of thousands of dollars a year by managing the out of plan care of members while ensuring appropriate care was provided. Managed the operations of three high volume call centers – Emergency Prospective Review Program (EPRP), Out of Plan Case Management, and Behavioral Health Care Call Line.
Coordinated the activities of the operations with internal and external departments and agencies.
Provided supervision of the staff including evaluations, discipline, etc. 1987 – 1991
Kaiser Permanente
Supervisor Outside Utilization Management
Los Angeles, California
Developed and implemented the Case Management of members who were admitted to non plan facilities and repatriate as indicated.
Supervised staff including scheduling, evaluations, discipline. 1979 – 1987
Kaiser Permanente
Staff Nurse
Registered Nurse
Los Angeles, California
Acted as charge nurse in the Intensive Care Unit, Medical Oncology Unit – making assignments.
Acted as resource for other staff members.
Medical Oncology – 1979 – 1984
ICU – 1984 -1987
1978 – 1979
Huntington Memorial Hospital
Pasadena California
Medical Oncology – provided bedside nursing, team leading, and charge nurse over a 30 bed floor.
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Sylvia A. Gyimesi
Registered Nurse / Case Manager
Education
1975 – 1977
Conestoga Nursing College
Stratford, Ontario
Canada
Associate degree – registered nurse
1970 – 1975
Woodstock Collegiate Institute
Woodstock, Ontario
Canada
High School - 5 year Arts and Science
St. Mary’s Elementary School
Woodstock, Ontario
Canada
References available upon request
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