Manager Medical

MERCEDES FERRERA, LPN

**** **** **** ******, *******, Florida 33012 Home 305-***-****

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

OBJECTIVE

To be an integral part of a professional organization with opportunities for growth and advancement. Experience in Benefit Administration with abilities in negotiations, pre-certification, case management and denial audits for a large Health Maintenance Organization. Extensive knowledge of Utilization Management concept and application of Managed Care setting. Strengths include knowledge sharing, adaptability, leadership and continuous process improvement. Focus on developing customer and vendor relationships, while always thriving in a constant changing work environment.

PROFESSIONAL EXPERIENCE

CONTINUCARE HEALTH PLAN Miami, Florida 2010- 2012

In House Case Manager

• Coordinate plan of care for patients that are admitted to hospitals as inpatient or 23hr observations, maintain daily communication with attending physician to insure interqual criteria and Medicare guidelines are met

• Communicate with primary care physician and Medical director the daily tracking of all admissions

• Assure of appropriate medical care follow up

• Arrange direct admissions, generate authorization for the admission with multiple health plans

• Maintain daily accurate admission and discharge logs

• Coordinate home health care for discharged patient needs

CARE PLUS HEALTH PLAN Miami, Florida 2006- 8/2009

Pre-certification/case manager

• Responsible for review of medical documentation apply Medicare guidelines for approval of surgical outpatient and inpatient request and durable medical equipment. CPT and ICD-9 knowledge assuring a determination within the allowable Medicare timeframe.

• Responsible for negotiations of rates to non participating providers

• Point of service contact for multiple M.S.O. offices.

• Team facilitator providing support and guidance to co-workers. Assisting with member services related issues and grievance/appeals.

• Gathering medical documentation and determination guidelines for medical director review. Work closely with the medical director providing all required documentation for case managing high cost members.

Key Achievements

• Providing Support to department co-workers, team facilitator providing assistance to co-workers with determination of medical request.

• Extensive knowledge in Medical determination process, Cost efficiency, assessment of patient medical needs.

• Star award recipient for providing perfect services

BLUE CROSS BLUE SHIELD OF FLORIDA Miami, Florida 1999-2006

Pre-certification (Care Support Nurse)

• Primary responsibilities include authorizing medical and surgical procedures both elective and Emergency Room admissions using Interqual criteria via Telephone and fax requests.

• Pre-authorized and authorized general medical cases, Infertility related cases on diagnosis and procedures with regard to medical necessity.

• Experience in Telephonic case management, Enrollment for Targeted Programs. Administer benefits for multiple lines of business including HMO, PPO, FEP, NASCO, Traditional and Medicare.

Key Achievements

• Represented Provider Care Support Team (PCST) Department with assisting Medical Director’s in revising Infertility protocols including CPT Coding Clarification for effective review of clinical information.

• Represented Provider Care Support Team (PCST) Department in Quarterly user group meetings to implement process improvements and to correct Inconsistencies with Corporate Medical Clearance Application.

• Part of a team responsible for Processing Denial Letters via Microsoft Access Database System.

• Responsible for Negotiation of rate for Non Participating providers

• Extensive Knowledge in Interqual, McKesson Systems and Knowledge with ICD-9 and CPT Codes.

• Gathering and assessing clinical information based on Medicare Guidelines and company policies.

CAC UNITED HEALTH CARE Miami, Florida 1990-2000

Nurse Manager

• Pediatric Nurse Manager supervised a staff of 25 at a Medical Center including Medical Doctors, Medical Assistants, and phlebotomist.

• Pediatric Patient Care responsibility included Emergency Room, Routine Care and Pediatric Immunizations.

• Coordinate staff work schedules, conduct employee evaluations and training.

• Process Medication orders for Crash Cart and Patient Assessment, Immunization and records.

• Implement Nursing Care Plans.

• Medical Coding and OSHA Guidelines.

PALMETTO GENERAL HOSPITAL Miami, Florida 1987-1989

L.P.N

• L.P.N Med Surgical Floor

• General Clinical Duties

• Medication Administration

EDUCATION

• Licensed Practical Nurse

• Miami Lakes Tech Miami, Florida

• Miami Dade Community College

COMPUTERS SKILLS

• Information Management System(IMS)

• Current Procedural Terminology Coding(CPT) ICD-9 CM Coding

• Care Enhance Review Manager (CERM,INTERQUAL)

• Microsoft Word, Excel, Outlook, Power point, Access Medical Coverage Guidelines (MCG)

TRAINING AND DEVELOPMENT

• Six Sigma Course (Yellow Belt)

• Care Enhance Review Manager (CERM)

• FEP General Training

• Denial Process Training

• Fraud Prevention Training

• Changes in Management HIPPA

• ICD-9 CPT Coding

AWARDS

• PCST Representative Recognition Champion Award 2years

• Hats Off Awards

• Thumb’s Up Awards

• Recognition Letter

• Perfect Service Awards 2years

Contact this candidate