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Registered Nurse Medical

Location:
Pasadena, CA
Posted:
August 10, 2020

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Resume:

MARYANNE SARMIENTO, BSN, RN, PHN

*** * ****** *** *** 9, Pasadena, CA 91101

Phone: 818-***-**** Email: *******************@*******.***

SUMMARY OF QUALIFICATIONS

My background and experience encompass a unique combination of medical management clinical and non-clinical operations. My responsibilities have required direct oversite of clinical, as well as non-clinical patient, provider, staff engagement areas. My roles have included the building, development, and implementation of strategic and innovative initiatives, including value driven, high risk, chronic care patient and provider programs. Key areas of expertise include: health plan and IPA/group level management of pre-service clinical operations (inpatient/outpatient referrals, denials, appeals/grievances, NOMNC, DSNP, CSNP Model of Care, 24/7 call center); regulatory monitoring, compliance; patient, provider satisfaction; policy, procedure, workflow and process enhancement.

EDUCATION

October 2017, West Coast University, Bachelor of Science in Nursing, Public Health Nurse

LICENSURE

California Registered Nurse, License Active Arizona Registered Nurse, License Active

Nevada Registered Nurse, License Active Texas Registered Nurse, License Active

PROFESSIONAL EXPERIENCE

Imperial Health Plan, Imperial Health Holdings Medical Group, Pasadena, CA

Medical Management, Utilization Management, Manager 01/17/2019 – 07/31/2020

Responsible for managing the day to day onsite / offsite, inpatient / outpatient, clinical and non-clinical operations of Utilization Management, including: pre-service referrals; denials; appeals; grievances; inpatient (i.e., hospital / SNF concurrent review); NOMNC; transitional care management / post discharge.

Responsible for managing the DSNP / CSNP Model of Care Program, including: Health Risk Assessments (HRA); Individualized Care Plans (ICP); and Interdisciplinary Care Team (ICT).

Successfully attained and maintained a compliance turnaround for Medicare / Medi-Cal lines of business, in coordination with the Director of Utilization Management. Achieving compliant outcomes (avg 65% to 95%+) within regulatory areas, including: prior authorization; denials; appeals and grievance; and UM call center statistics.

Successfully managed clinical review of acute facility admissions / re-admissions to significantly reduce Medicare bed-days/K (avg 1400/K to 850/K) and < 4.2 ALOS (average length of stay).

Responsible for development and implementation of UM Workplan initiatives, monthly / quarterly updates, annual evaluation and health plan reporting.

Responsible for coordinating with the UM Director the Utilization Management Committee meetings, minutes, and health plan reporting.

Responsible for coordinating with the Compliance Manager the monthly health plan reporting requirements, including ODAG (Organization Determinations Appeals Grievances).

Responsible for assigning and monitoring daily workflow assignments for all clinical and non-clinical staff, including coordinators, nurses, and medical directors.

Responsible for ensuring the implementation of the UM process as it relates to quality of care and assuring that corrective actions are taken when problems are identified.

Responsible for coordinating with the Medical Director the annual clinical / non-clinical staff IRR (Inter-Rater Reliability Survey)

Responsible for oversite in coordination with the Compliance Manager of audit review of pre-service authorizations / denials / grievance and appeals to ensure accuracy and compliance with all regulatory requirements.

Responsible for assisting with recruiting, training and mentoring clinical and non-clinical staff in regard to position and company expectations, including: developing, monitoring, and appraising job results; coaching, counseling, and disciplining employees; developing, coordinating, and enforcing systems, policies, procedures, and productivity standards.

Participate as a key stakeholder in gathering of pertinent UM and related data used to identify and evaluate trends and options, selecting a course of action; defining success metrics and evaluating outcomes.

Responsible for maintaining quality service by enforcing quality and customer service standards; analyzing and resolving quality and customer service problems; identifying trends; recommending system improvements.

Responsible for assisting the Claims Department with claims retrospective authorization / medical record review. Including, research inpatient and outpatient medical claims to determine appropriate payment and level of care approved.

Participate as a key resource within the workflow / process planning, integration and implementation of the EZCAP / Citra system.

Valley Presbyterian Hospital, Van Nuys, CA

Clinical Registered Nurse (Per Diem) 10/2018 – 12/2018

Responsible for conducting an individualized patient assessment, prioritizing the data collection based on the patient’s immediate condition or needs within timeframe specified by client facility’s policies, procedures, or protocols.

Responsible for conducting ongoing assessments as determined by patient’s condition and/or the client facility’s policies, procedures or protocols and reprioritizes care accordingly, while maintaining PHI / HIPAA confidentiality.

Responsible for developing a plan of care that is individualized for the patient reflecting collaboration with other members of the healthcare team. Perform appropriate treatments as ordered by physician in an accurate and timely manner. Perform therapeutic nursing interventions with the interdisciplinary care team (ICT) as established by individualized plan of care f(ICP) or the patient and his/her family.

Engaged with patient / family members to deliver care with appropriate age and cultural competence to specific patient populations according to individualized needs. Document patient assessment findings, physical/psychosocial responses to nursing intervention and progress towards problem resolution.

MEDPOINT Medical Management, Woodland Hills, CA 07/2018 – 08/2018

Inpatient Concurrent Review Case Manager (Per Diem)

Responsible for completion of initial, concurrent, peer review, expedited appeal review, and retrospective reviews in a timely manner to ensure continuous coverage.

Utilized clinical information and knowledge of Medi-Cal line of business to apply the necessary criteria to effectively communicate plans of care with health plan case managers, facility staff, and affiliated healthcare providers.

Collaborated with clinicians daily in order to obtain necessary clinical for review and ensure appropriate lengths of stay and effective utilization of resources. Including: tracking clinical timeframes; updating authorizations / denials within the clinical systems; assuring interdepartmental communications; communicating post discharge plans with health plans / providers.

Responsible for appropriately applying medical hierarchy of use: NCD, LCD, MGG, health plan / other.

Star Home Health Care, Granada Hills, CA 07/2018 – current

Nurse Case Manager (Per Diem)

Responsible for providing Nurse Case Management oversite to ensure appropriate application of an established physician plan of care.

Perform onsite Nurse Case Management including, but not limited to: physical care; emotional support; patient and family education; administration of medications and treatments prescribed by the physician; and preparation and care of any physician ordered specialized treatments.

Participate as a Nurse Case Manager including documentation used in collaboration and review in conjunction with the Individual Care Plan (ICP) and Interdisciplinary Care Team (ICT).

Provide Nurse Case Management oversite in accordance with regulatory and agency guidelines.

Nursing Program, West Coast University 11/2014 – 10/2017

Successfully completed all aspects of RN nursing program. Relevant onsite clinical experience within the following facilities: Children’s Hospital of Los Angeles (Dialysis); Glendale Memorial Hospital (ED/ICU/CCU/Telemetry; Los Angeles Unified School District (Public Health Nurse); Kaiser Permanente Medical Center Panorama (Medical/Surgical); White Memorial Hospital (Pediatrics); Good Samaritan Hospital (Labor/Delivery, Neonatal ICU); Silver Lake Medical Center (Psychiatry); Hollywood Presbyterian Hospital (Medical/Surgical).

Heritage Provider Network / Regal Medical Group / Lakeside Community Healthcare, Northridge, CA

Campus Support Center (Patient / Provider Engagement), Senior Team Lead 03/2008 – 02/2016

Responsible for the build / develop / implementation of workflows / processes / policies / protocols within a new organization department, in conjunction with the V.P. of Campus Support Center and the Chief Medical Officer.

Responsible for hiring / training and supervising 15+ employees handling multiple Medical Management related organizational initiatives, including call center operations for over 500+ inbound / outbound patient / provider communications / day.

Responsible for providing special project support for “Regional Campuses” within Southern California, including: Medical Management (ER Avoidance for Ambulatory Care Sensitive Conditions (ACSC); Urgent Care Education; OB Prompt Discharge Program; Transitions of Care / Post Discharge Re-Admission Reduction Program; Palliative / Hospice Transitions); Provider Relations / Contracting (Specialty Termination Transitions / Continuity of Care (COC)); HEDIS / HCC (Annual Wellness Visit / Vaccinations / Screenings/ Chronic Condition Program (i.e., diabetes) outreach / patient education).

Responsible for 24 / 7 Campus Support Medical Management Call Center Operations, including: developing clinical resource routing protocols during after-hours / weekend / holidays (i.e., SNFists, Hospitalists, Case Managers) and non-clinical staff (i.e., inpatient coordinators) 24 / 7 scheduling; developing ACD call queues to ensure timely routing of patient / provider issues to the appropriate clinical resource during normal business hours.

Responsible for the build, develop, implementation, staff supervision, in conjunction with the V.P. of Campus Support Center and the Chief Medical Officer, of a “new” online patient / provider engagement portal program - “Early Bird Alert”. 10K+ Medicare Advantage members with high risk / chronic conditions were aligned to participate in the program.

Responsible for Early Bird Alert Program initiatives, including: development of marketing materials; patient education / outreach (i.e., portal training / access, high risk condition programs / education); onsite clinic patient / provider / staff portal training; user and engagement outcomes. Provide patient information, such as: claims, authorizations, insurance benefits, eligibility, and contracted PCP / specialist network.

Responsible for assisting with “Open Enrollment” call center operations, including: broker information; health fairs; and related health plan specifics within the Medicare regulatory requirements.

Responsible for Next Gen ACO “Healthy Options” Program, high risk, chronic condition patient / provider initiatives, including: call center metrics; monthly event (i.e., health fairs, movies, museums) reservations (online and call center initiated); chronic condition program education / outreach.

SOFTWARE / MEDICAL CRITERIA PROFICIENCY:

Milliman, NCD/LCD, Anthem (AIM), Medicare, Medi-Caid/Medi-Cal, DSNP, CSNP, HMO, PPO, EPO, Word, PowerPoint, Visio, Publisher, EPIC, EZCAP/CERNER, E-CLINICAL, ACCESSXPRES

CERTIFICATIONS

CPR, BLS, FIRE SAFETY, ECG, PHARMACOLOGY, ACLS, PALS, NIHSS, SKS PEDIATRIC CARDIAC CARE

LANGUAGES SPOKEN

English, Tagalog (Filipino), Spanish

COMMUNITY AFFILIATIONS

Los Angeles County Sheriff’s Department Mental Health Court

Zoe Rescue Walk- My Fight! Ending Child Trafficking

Meet Each Need with Dignity (MEND) Poverty

References Available upon Request



Contact this candidate