Registered Nurse Medical
Resume:
Marie Gilberte Redon **** NW **th Drive, Coral Springs, FL 33065
Cell: 786-***-****
Email: *********@*****.***
Objective
Seeking a position as an RN, utilizing specialized training and outstanding communication skills in the healthcare setting.
Licenses
Registered Nurse, licensed in multiple states
CPR certified through American Heart Association
IV certified
Education and Training
Jersey College Nursing School – May 2019
Registered Nurse (RN)
Miami Lakes Technical Center – July 2009
Licensed Practical Nurse (LPN)
Trinity Home Health, Fort Lauderdale
March 2019 to present
Provide and direct provisions of nursing care to patients in their homes as prescribed by the physician and in compliance with applicable laws, regulations and agency policies.
Coordinate total plan of care with other health care professionals involved in care, and help to achieve and maintain continuity of patient care by planning and exchanging information with physician, agency personnel, patient, family, and community resources.
Professional Experience
Prior-Authorization Nurse (RN)
July 2019 to Present
Sunshine Health Plan – Sunrise, FL
Identify appropriate benefits and eligibility for requested treatments and/or procedures.
Conducts prior authorization reviews.
Assess services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Process requests within required timelines.
Refer appropriate prior authorization requests to Medical Directors.
Make appropriate referrals to other clinical programs.
Collaborate with multidisciplinary teams to promote Molina Care Model
Adhere to UM policies and procedures.
CRC/Care Review Clinician (LPN)
August 2015 to April 2019
Molina Healthcare – Doral, FL
Assess services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
Analyze clinical service requests from members or providers against evidence based clinical guidelines.
Identify appropriate benefits and eligibility for requested treatments and/or procedures.
Conduct prior authorization reviews to determine financial responsibility for Molina Healthcare and its members.
Refer appropriate prior authorization requests to Medical Directors.
Collaborate with multidisciplinary teams to promote Molina Care Model
Adhere to UM policies and procedures.
Licensed Practical Nurse
UM Clinical Specialist, LPN
August 2011 to August 2015
Univita Healthcare Solutions- Miramar, FL
Review accurately all directions per Medical Doctor (MD) orders and coordinates all request for services and care as per contractual arrangements, policy and workflow for coverage of benefits and/or medical necessity both pre or post service and verification of eligibility for types of services as per Health Plan specific direction.
Interpret medical policy and benefit plan descriptions for covered and medically appropriate benefit decisions. Uses available resources and guidelines (including but not limited to Health Plan contractual arrangements, Medicare, Medicaid, Millimen guidelines) and other clinical resources, guidelines/ criteria as needed.
Promote network provider compliance and quality home health care.
Provide oversight to non-clinical staff for guidance and review for the pre-screening process for precertifications.
Responsible for meeting daily production and turnaround times and all contractual arrangements plus handle any provider/beneficiary/ health plan calls.
Provide availability as a resource to Providers, Health plans, other staff and referral sources while educating & supporting the Utilization Management Program.
Participate in on-call, after hours, weekend and holiday support for the department as scheduled.
Extensive experience with Second level review (SLR)
Licensed Practical Nurse
November 2009 to August 2011
Enjoyable Home Healthcare – North Miami, FL
Provided palliative care to patients.
Provided nursing care to status post-surgical patients and performed ongoing physical assessments.
Pain Management, Wound Care Management, and Rehabilitative Restoration.
References: Furnish upon request
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