Case Management Mental Health
Resume:
LETICIA RUIZ, RN
CONTACT
PROFILE
Orange Grove, TX 78372
*******@*******.***
Registered Nurse with 19 years of experience practicing in various of roles from acute care bedside, Case Management for acute and community, Auditing, Audit Team Management, Process Improvement, Director of Nursing for outpatient Mental Health services, auditing tool development, Service Coordination, MCO contract compliance, MMP, DSNP, SNP contract and processes, developed training material, Trainer, collaborated on MCO policy development and process updates, reported Key Performance Indicator scores to Senior Leadership, with action plans for metrics not met, Medical Necessity clinical reviews for preservice, acute care admission, continued stay, observation, ambulatory services, DME, Home Health, Rehab, Skilled Nursing Facility and Retro reviews using the appropriate criteria source, prepared concise clinical documentation and criteria used for Medical Director determinations when criteria were not met.
My goal is to obtain a position and use my experience and knowledge to complete clinical reviews for services requested using the designated criteria.
SKILLS
EXPERIENCE
Excel
Word
Teams
Zoom
Management
Case Management
Discharge Planning
MCO Contract review
Auditing
Disease Management
Medical Necessity
Preservice/Prior Authorization
Concurrent reviews
Retro Reviews
Ambulatory Service reviews
DME PA reviews
Home Health reviews
Skilled Nursing facility reviews
LTAC reviews
Adverse Determination
Utilization Review
Utilization Management
InterQual
Milliman
NCD, LCD, EOC, COB, HCBS
PPO, HMO, MCO
CPT /ICD-10
Key Performance Indicators
Quality Metrics
STARS grading system
HIPAA
NCQA
CCM certified
HEDIS
CAHPS
Risk Management
Director of Nursing for MHID
Social Determinants of Health
Electronic Records systems
Toggle multiple programs for reviews
Detail oriented/analytical
Dependable
Dedicated
Adapts well to change
Effective communication skills/verbal and written
Collaborative
Professional
Timely
Diversity, Equity, and Inclusion
Meet Deadlines and Metrics
Remote positions held
Motivated
Ambitious
Quick learner
10/2023-4/2024
Concurrent Review Nurse-Remote
Contract via CareNational/Centene Corporation
Responsibilities: prompt reviews for inpatient admissions, continued stay, observation and outpatient procedure levels of care with a 24-hour turnaround time for review completion. InterQual criteria used. Collaborated with Discharge Planning, Case Management, Disease Management and Medical Director via weekly rounds for best DC plan to prevent readmissions. Prepared Medical Director review requests for unmet criteria to begin denial process. Communicated with team members electronically in this remote environment position. Participated in team meetings. Promptly reviewed communications regarding process changes and implemented such changes timely. Maintained company policies and processes. Metric for concurrent review was 11-13 daily. Management provided positive feedback regarding meeting metrics.
11/2022-8/2023
Prior Authorization Medical Necessity Review Nurse-Remote
Contract via The Judge/Wellmed Medical Management
Duties-Medical Necessity reviews for all levels of care using required criteria sources-Met daily metrics of 21 case reviews per day-provided accurate and complete documentation with rationale used to approve request-Discharge Planning collaboration with social workers, Medical Directors, Case Managers, Behavioral Health CMs, and Disease Managements about network status-Medicare Benefit Policy Manual for Home Health reviews, NCD, LCD, individual health plan policy criteria-CPT and ICD 10 reconciliation. Communication with Medical Directors for unmet criteria and subsequent adverse determination process.
8/2021- 10/2022
Director of Nursing-
Mental Health and Intellectual Disability for Nueces County
Responsibilities included oversight and management of our Outpatient Medical and Medication Psychiatric Clinic, complete process and policy reviews and recommend specific revisions based on contracts, Oversight and adherence reviews for CMS guidelines and safe nursing practices, maintained our psychotropic medication sample inventory, participated in various committees such as Safety Committee, EHR Committee and Joint Commission preparedness, ensured we follow nursing practices according to our Center’s policies and procedures. Oversight and management of inventory for clinic medical supplies. Ensured compliance with local, state, and federal contractual requirements and policies as well as Joint Commission’s clinical requirements and guidelines, Performed annual evaluations of the nursing staff. Planned, assigned, and supervised the work of others. Served as educator for proper technique for nursing procedures with regards to Injectable antipsychotics including MOA for all psychiatric medications we prescribed. Served as the charge nurse and maintained the patient flow. Consulted with the Center’s Mental Health Director of Operations and Medical Director on complex issues. Performed audits to ensure performance measures were met. Performed as the Infection Control Designee, responsible for tracking, monitoring and reporting any communicable diseases/infections to Safety Committee in compliance with the Center’s Infection Control Plan and The Joint Commission. Worked under general direction with extensive latitude for the use of initiative and independent judgment. Assisted with Mental Health Case Manger Acute Crisis patient episodes to the extent of Nursing evaluation and Intake Data.
9/2018-6/2020
Process Improvement Specialist-
Centene Corporation, Corpus Christi, TX
Updated and created new processes and policies. Managed and supervised new projects and clinical initiatives. Reviewed, analyzed, and reported on several scorecards such as Stars, and multiple Process Improvement Measures and Metrics that were driven by corporate, state, and federal guidelines.
6/2015-9/2018
Quality Auditing Department Manager-
Centene Corporation, Corpus Christi, TX
Job duties: Developed Auditing Tools for multiple departments across the health plan. Maintained monthly Comprehensive Audit Report reviews with Department Managers. Managed and maintained auditing practices for three levels of Service Coordination, and the following departments: Intake, Scheduling, Authorizations, and Appeals/Denials. Communicated with Senior Leadership daily for Process Improvement and new business items. Actively participated in decision making with leadership. Assisted in preparation for corporate mock audits and real time on-site state and federal audits.
1/2014-6/2015
Clinical Auditor/Trainer-
Centene Corporation, Corpus Christi, TX
Job duties: Developed and maintained the audit process and audit tools related to Service Coordination positions. Assessed training needs and communicated with on-site trainers to develop appropriate training programs for staff. Audited staff in accordance with established auditing processes. Worked with cross-functional teams to present findings and recommendations for improvement. Trained audit staff in the use of audit tools. Maintained records of employee progress. Assisted with revisions to Policy and Procedure and/or work process development.
1/2013-12/2013
RN Service Coordinator-
Centene Corporation, Corpus Christi, TX
Job duties: Collaborated with medical, behavioral, and social support staff to ensure appropriate discharge planning for our membership. Facilitated in arranging appropriate services needed for a safe discharge. Educated staff and members on benefits such as DME, Private Duty, and HH. Reviewed PAS requests for necessity. Completed member assessments, telephonic and face to face. Served as back up Lead Service Coordinator. Presented evidence in Fair Hearings. Completed data reviews and reported productivity to senior leadership. Provide clinical input for the development of policy and procedure.
9/2012 – 12/2012
Acute Care RN Case Manager-
Mediscan Staffing for Travel Nursing, UCLA, Santa Monica, CA
Responsibilities: completion of initial/admission and continued stay MN Reviews using appropriate criteria based on Medical Coverage Plans, conducted comprehensive patient/family assessments for discharge planning, evaluation upon admission, maintained and updated the patient’s discharge plan of care. Lead DCP rounds daily. Collaborated with other acute care disciples for the safest DCP possible to prevent readmissions.
11/2010-9/2012
RN Case Manager II-
Centene Corporation, Corpus Christi, TX
Responsibilities include utilization review, reviewing for medical necessity for various medical services from DME to Home Health Skilled therapy. The average case load for the underserved members in the community was 75. I case managed the chronically ill with multiple co-morbidities population. Provided patient education with purposeful plans of care. Facilitated arrangement of services the members required.
2008-2010
RN Case Manager-
CHRISTUS Spohn Hospital, Corpus Christi, TX
Responsibilities: chart reviews, managing length of stay, giving clinical information to insurance companies. Collaborated with the physician to develop a safe and effective discharge plan. I assisted with transitional care arrangements to the next appropriate level of care.
2005-2007
Acute Care Registered Nurse Telemetry/Post Interventional-
CHRISTUS Spohn Hospital, Corpus Christi, TX
Responsibilities: provided nursing care to cardiac patients with multiple comorbidities, maintained a Nurse-Patient ratio of 1-6, included ongoing prioritizing of care. Skills care: IV drip therapy, education, medication administration, rounding with physicians, preparing patients for procedures, collaborating with multiple disciplines to coordinate holistic patient care, and performed as Charge Nurse based on rotation for a 27 bed Unit.
2004-2005
Acute Care- Telemetry Student Nurse Tech II
CHRISTUS Spohn Hospital, Corpus Christi, TX
Performed nursing procedures with direct bedside nurse oversight and
according to facility policy while completing nursing school.
EDUCATION LICENSURE CERTIFICATION
2003-2005 Del Mar College, AA in Applied Science, Registered Nursing
2005-CURRENT Texas Board of Nursing, Registered Nurse License #719608
2013-2026 Commission for Case Manager Certification, Certified Case Manager #00143051
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