Case Manager Clinical Review

Ms. Pajarillo, ReyMavil LVN UM CM DCP

Contact: 562-***-****

Email: ***.***********@*****.***

Objective

Positive impact willing to expand knowledge and skills, educate based on experience of training, and thrives for GROWTH AND SUCCESS AS A TEAM. To continue on providing POSITIVE feedback as a Patient/Advocate and Coordinate Leadership for the Healthcare Team.

Education

• COLLEGE: GRAND CANYON UNIVERSITY (ONLINE PROGRAM)

DEGREE: BACHELOR OF HEALTH SCIENCES (in Progress - GRADUATING: JUNE 2023)

• College: Guam Community College Certified Vocational Nursing Graduated: 01/2009

• Marianas Training School Certification: Phlebotomy Technician Graduated: June 2007

• High School: Bataan Christian School (4years) Certification / Diploma: Graduated 2000

Licenses / Certifications

Board of Vocation Nursing

LICENSE#: VN253796

Expiration date: 11/30/2026

(ACTIVE)

CPR / BLS Healthcare Provider (American Heart Association)

eCard Code: 215**********

Expiration Date: 08/2026

(ACTIVE)

Professional Experience

Optimal Health (Part-Time)

Case Manager -South LA Region

— —

West Anaheim Medical Center (Full-Time))

Jan 2021 – Contract ended

TRANSITIONED Per Diem

Case Manager / Discharge Planner / Quality Assurance & Grievance Care Processor

• Assigned Units: Medsurg, Telemetry, DOU, ICU, CCU

• Inpatient clinical review and Discharge Coordinator.

• Provide a safe and smooth disposition of inpatients assigned to meet all measures of quality care, including acknowledgment of grievance reports along with initiating proper response per protocol.

• Assure a safe discharge and complete transfer upon clinical intervention and stability of patient’s case.

Anaheim Regional Medical Center

March 2021- MARCH 2022 (Contracted ended)

Case Manager / Utilization Management / Clinical Review Nurse

• Units: MedSurg, Telemetry, CVOU, DOU, ICU

• Concurrent Case Management Clinical Review

• Obtaining patient’s level of care, confirm MCG criteria

• Coordinate and obtain orders from Medical Doctor attending to assigned patients.

(PLS TURN TO NEXT PAGE. Thank You)

Molina Healthcare

Dec 2019 – Jan 2021 (Contract ended)

Utilization Management / Prior Authorization Clinical Review (Remote Nurse)

• Clinical Case Review for Prior Authorization Request, using Interqual (IQ) tools

• Process and complete “Approve,” “Denial,” and “Appeals” with appropriate criteria

• Coordinate all cases processed to assigned contracted Provider, MD, and/or member.

• Meeting daily productivity and communicating with assigned Manager

• Assist with Peer to Peer for Reconsideration. Audits. Urgent Phone Request for Authorizations.

Torrance Memorial Outpatient

Jan 2019 – Dec 2019 (Contracted-ended)

Case Manager / Wound Care Specialist

• Obtain and review prior authorization. Assess patient in home settings. Complete request for proper DME and medical supplies as needed to meet patient’s medical needs.

• Monitor for medication compliance, family support, safety measures, and follow up appointments.

• Complete documentations/485s. Review Obtain signature from Assigned Physician.

• Patient Advocate to better understand and adapt to living self with assistance.

• Report for any changes of condition. Discharge planning to met goal and reduce hospitalization.

Enhanced Care Home Health

Feb 2018 – Dec 2018 (Relocated)

Outpatient Case Manager / Supervisory Field Nurse

• Obtain prior authorizations. Coordinate with assigned MD, proper Dx and level of care for weekly assessment/chart review.

• Assist with proper documentations from assigned nursing/SW/PT/OT/ST providing care.

• Complete 485s for insurance requirements. Critical care review.

• Manage patient’s medical and durable medical equipment needs.

• Report to MD/staff for any changes. Discharge patient after progress of ADL

Rancho Los Amigos Rehabilitation Center

June 2015 – Dec 2017 (Contract extended)

Inpatient Case Management / Home Health / DME / Discharge Coordinator

• Coordinate Patient’s Plan Of Care with Physician. Obtain private/managed insurance authorization.

• Initiate in-house Authorization. Obtain and review prior authorization. Complete additional documentation to justify patient’s medical needs and proper follow up to meet deadline and payment from insurance as needed d/t time sensitivity.

• Verify authorization with patient’s length of stay, diagnosis, nursing care, and level/rate agreed upon review/changes. Report changes. Make recommendations and/or referrals within covered area.

• Assess and prescribe for patients medical needs and process all Home Health/DME orders for safe discharge, per MD’s request. Review Plan of Care. Report and Coordinate patient’s care at home settings.

• Monitor and coordinate length of stay and level of care. Review chart for patient’s medical needs and report any change of conditions to MD, Health plan, and Home Health.

• Outpatient referral f/u with specialist(s) or non-specialist(s), coordinate scheduled visits, carry out new orders of visit, report to home health (if any HHA is assigned), report to insurance, complete documentation, and f/u with assigned Physician with next scheduled visit for patient/ family to acknowledged Care Coordinator’s advocate teachings upon visit/discharge.

• CM audits, NCQA accredited organizations, constructed health plans and site reviews.

REFERENCES:

• Ms. Tress Villa 562-***-**** UM LEAD Manager, RN

• Ms. Griselda Jimenez 562-***-**** Outpatient Lead DCP, RN

• Ms. Akiko Angeles 562-***-**** Administration LEAD / WoundCare Specialist, BSN

Contact this candidate