Patient Care Case Management

ER

ESTER RODRIGUEZ MONTANO

**********@*****.*** +1-305-***-**** Miami, FL 33174

Experienced nursing professional bringing demonstrated clinical expertise, leadership skills and technical knowledge. Proficient in updating charts, monitoring medications and working with multidisciplinary teams to optimize patient care. Quality-driven and efficient with strong interpersonal abilities. Seeking position as Registered Nurse that allows me to use my clinical knowledge, experience in a vast variety of clinical areas. I possess exceptional communication skills in English and Spanish. I have a team oriented mind set to elevate patient care and support the organization.

CASE MANAGEMENT (10+ years)

Utilization Review (6 years)

HEALTHCARE (Less than 32 year)

ONCOLOGY (10+ years)

RN

Home Health

Personal Injury

Counseling

Documentation

Management

Mental Health

Microsoft Office

Problem solving

Nursing

Primary Care Experience

Nurse Management

Medication Administration

Microsoft Excel

Discharge planning

Spanish

Motivational interviewing

Triage

DoD Experience

Epic

ICU Experience

Utilization review

Outpatient Care

Inpatient Care

Communication

Utilization Management

Documentation And Reporting

Home Health Care

Interpersonal and written communication

Insurance Verification

Medicaid knowledge

Performing assessments

Needs Assessment

Palliative Care

Quality Improvement

Records analysis

Nursing Consultation

Direct Patient Care

Surgical Assistance

Wound Care

Rehabilitation Assistance

Student Precepting

Instrument Sterilization

Case Management

Treatment Preparation

Vitals monitoring

Patient Examination

Care Coordination

Infection Control

Collecting vitals

Medication and IV administration

Patient Care Assessment

Task Prioritization

Blood Draw and Sample Collection

Crisis Prevention Intervention (CPI)

Diabetes management

Problem-solving aptitude

Teamwork and Collaboration

Critical Thinking

Excellent Communication

Reliability

Effective Communication

Professional Demeanor

Colostomy care familiarity

Compassionate and Caring

Accurate Documentation

Geriatric treatment knowledge

Patient Education

Summary

Skills

HIPAA Compliance

Patient Care Plans

Safety Protocols

CVS Aetna Better Health of Florida

(Contract) Miami, FL

Healthcare Consultant

01/2024 - Current

The RN Case Manager is responsible for thelephonically and/or face to face assessment, planning, implementing, and coordinating all case management activities with members to evaluate the medical needs of the member to facilitate the member's overall wellness. Develops a proactive course of action to address issues presented to enhance the short and long-term outcomes as well as opportunities to enhance a member's overall wellness through integration. Applies clinical judgement to the incorporation of strategies designed to reduce risk factors and barriers and address complex health and social indicators which impact care planning and resolution of members issues. Assessments take into account information from various sources to address all conditions including co-morbid and multiple diagnoses that impact functionality.

Reviews prior claims to address potential impact on current case management and eligibility.

Assessments include the member's level of work capacity and related restrictions/limitations.

Using a holistic approach assess the need for a referral to clinical resources for assistance in determining functionality.

Consults with supervisor and other in overcoming barriers in meeting goals and objectives, presents cases at case conferences for multidisciplinary focus to benefit overall claim management. Utilizes case management processes in compliance with regulatory and company policies and procedures.

Tricarepatient Utilization Review

NursTricareNurse Miami, FL

Tricare Utilization Review Nurse

02/2023 - 06/2023

Provides first level RN review for all outpatient and ancillary prior authorization requests for medical appropriateness and medical necessity using appropriate criteria, referring those requests that fail review to the medical director for second level review and determination Completes data entry and correspondence as necessary for each review. Assessed patient medical records to determine the appropriateness of requested services and procedures.

Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.

Provided education to providers regarding utilization management processes and protocols.

Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.

Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.

Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services. Developed case management plans based on individual patient needs and eligibility criteria.

Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions. Determined medical necessity and cost-effectiveness of services through Experience

utilization review processes.

Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.

Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries. New Century Health Miami, FL

Utilization Review Nurse

05/2019 - 11/2022

Utilization Nurse clinical reviewer/Utilization management. Assessed patient medical records to determine the appropriateness of requested services and procedures.

Conducted reviews of inpatient utilization for compliance with admission criteria and concurrent review requirements.

Provided education to providers regarding utilization management processes and protocols.

Collaborated with multidisciplinary teams on developing strategies for improving care quality and controlling costs.

Evaluated clinical documentation for accuracy and completeness in order to make decisions about coverage determinations.

Reviewed denial letters issued by insurance companies to ensure that they were appropriate and timely.

Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services. Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.

Performed discharge planning including referrals for post-acute care services when appropriate.

Participated in provider meetings to discuss cases involving complex medical conditions or difficult authorization decisions. Identified opportunities for improvement within the utilization review process through data analysis.

Attended conferences and training sessions related to utilization review topics such as best practices or new technologies. Determined medical necessity and cost-effectiveness of services through utilization review processes.

Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.

Collaborated with providers to obtain required clinical information, supporting prior authorization determinations and individual inquiries. Referred cases to secondary review for failure to meet criteria. United Health Care Military and Veterans

Miami, FL

Nurse Case Manager

05/2017 - 12/2018

Coordinate, or provide appropriate levels of care under the direct supervision of an MD

Function is responsible for clinical operations and medical management activities across and continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)

This includes case management coordination of care, and medical management consulting

Function also includes providing health education, coaching and treatment decision support of beneficiaries.

Coordinate, or provide appropriate levels of care under the direct supervision of an MD

Function is responsible for clinical operations and medical management activities across and continuum of care (assessing, planning, implementing, coordinating, monitoring and evaluating)

This includes case management coordination of care, and medical management consulting

Function also includes providing health education, coaching and treatment decision support of beneficiaries.

Sylvester Comprehensive Cancer Center

Miami, FL

University of Miami

05/2007 - 12/2017

Provided primary care to patients, including diagnosis and treatment of illnesses.

Assessed patient health by interviewing patients, performing physical examinations, and ordering lab tests.

Educated patients about health maintenance, disease prevention, and lifestyle changes.

Monitored patient progress and provided appropriate follow-up care. Prescribed medications according to established protocols. Instructed patients on proper use of medications and monitored effectiveness of treatments.

Coordinated with other healthcare providers to ensure optimal patient outcomes.

Maintained accurate medical records for all patients utilizing electronic medical record systems.

Developed individualized plans of care based on assessment findings and physician orders.

Participated in interdisciplinary teams to develop comprehensive plans of care for each patient's needs.

Provided compassionate support to families facing difficult decisions regarding end-of-life issues.

Referred patients to specialists or other healthcare professionals as needed for further evaluation or treatment.

Counseled patients on healthy lifestyle choices such as nutrition and exercise habits.

Assisted physicians during exams, procedures, and surgeries as necessary. Demonstrated sensitivity when working with diverse populations from various cultural backgrounds.

Reached out to patients to convey lab results and provide care instructions. Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions. Helped patients and families feel comfortable during challenging and stressful situations, promoting recovery and reducing compliance issues. Assessed patient conditions, monitored behaviors and updated supervising physicians with observations and concerns. Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.

Grand Canyon University

MSN in Adult Gerontology Primary Care Nurse Practitioner 03/2024

NOVA SOUTHEASTERN UNIVERSITY Miami, FL

BACHELORS OF SCIENCE in NURSING

05/2016

Education and Training

Certified Case Manager

Nurse case manager

Legal nurse consultant

BLS/CPR / ACLS

AED Certification

RN License

701B Certification

701T Certification

SKILLS & ABILITIES Registered Nurse

Highly skilled professional with more than twenty years' clinical experience in hospital, home health, Utilization review, case management, and primary care environments, Charge Nurse, Nurse Manager, Office lead Nurse. Established in Oncology for over ten years. Patient support including: assessment, counseling, education, teaching, review of treatment plan; medication management and administration. Review of patient care plan, triage and management of symptoms with collaboration of other healthcare team members. Initiate and follow up on prior authorization for chemotherapeutic agents and follow through with utilization review of indicated diagnostic testing. Perform head to toe assessment during patient monthly visit, reinforce or initiate new patient teaching, review medication side effects, and coordinate diagnostic testing. Proficiency in all areas of major and minor surgical procedures performed in hospital, in-patient, outpatient environment Previous CNA, LPN experience.

Fluent in Spanish and English (speak/write)

Exceptional emotional intuitiveness QUALIFICATIONS United States citizenship LICENSES/CERTIFICATE

Registered Nurse Florida RN9305309

Registered Nurse Wyoming RN40831

Certified Case Manager (CCM) 4233459

701B Certification

701T Certification

Department of Defense NAC clearance.

Work Permit: Authorized to work in the US for any employer Spanish:

Native/ Bilingual

References available upon request.

Certifications

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