Ailyn Cruz
Pompano Beach,FL
Summary
Caregiving professional with 10 years of experience in providing quality care management for adult and pediatric population. Develops tailored care plans meeting unique needs of clients. Passionate about providing clients with high-quality care to improve quality of life.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Long Term Care Case Manager for Geriatric and Psychiatric Population
FLORIDA CARE MANAGEMENT SERVICES AGENCY
08.2018 - Current
- Responsible to provide full case management services on over 60 designated cases with client and family/caregiver(s)
- Provide crisis intervention services to individuals facing medical, emotional and mental health challenges
- Identify, escalate, and resolve complex cases or issues as required
- Assess risk factors of patients and made referrals for further services
- Create individual care plans and update as required
- Establish and maintain effective relationships with internal and external partners
- Organize and maintain client files up to date for AHCA audits
- Evaluate medical guidelines and benefit coverage to determine appropriateness of services
- Perform prior authorization review of services requiring notification
- Analyze medical records and other documents to determine approval of requests for authorization.
Patient Care Coordinator
SOUTH FLORIDA PULMONARY CARE, INC.
01.2017 - 08.2018
- Developed and implemented comprehensive case management plans to address client needs and goals
- Monitored clients' progress and tracked client services to provide crisis interventions
- Acted as main point of contact for patients, doctors, and hospital staff by closely reviewing medical charts and maintaining high levels of communication
- Worked with patients to schedule tests and procedures
- Upheld confidentiality requirements and regulatory compliance guidelines
- Built safety plans to lower risk of crisis and intervened in specific manners outlined by procedures
Behavioral Health Specialist
MOLINA HEALTHCARE, INC.
08.2015 - 11.2017
- Worked closely with members to understand their medical conditions, treatments, and other factors that affect their healthcare\
- Managed high volume caseload of over 100 members with diverse needs
- Developed care plans that addressed members' healthcare needs, including medical treatments, medication management, and referrals to other healthcare providers
- Coordinated care and services such as scheduling appointments, coordinated transportation, and communicated with providers to ensure quality care
- Communicated with members and their families to help members navigate the healthcare system and resolve any issues or concerns
- Educated patients about common mental health and substance abuse disorders to facilitate understanding of treatment options.
- Ensured compliance with insurance plan policies/regulations and provided education and guidance to members on how to access and use their insurance benefits effectively.
- Used skills such as active listening and collaborative problem-solving daily to connect with patients and address concerns.
- Evaluated risk to client or others by gathering information and conducting assessments.
Behavioral Case Manager (SED)
PSYCHSOLUTIONS, INC.
03.2015 - 07.2015
- Provided mental health case management services to children with severe emotional disturbances
- Conducted assessments and evaluations of children's needs, strengths, and goals
- Served as a liaison for the client, family, referral source and other social service agencies
- Developed and implemented individualized care plans in collaboration with families, service providers, and other professionals
- Coordinated and monitored the delivery of community resources and services, including medical, educational, and social services
- Advocated for the rights and needs of children and their families
- Ensured compliance with all relevant laws, regulations, and policies related to service delivery
- Assisted families in navigating the social services system, including applying for benefits, accessing resources and connecting with other family support services
- Intervened in crisis situations and counseled children experiencing emergencies and disruptive incidents
Medicaid Eligibility Specialist
MEDASSIST SOLUTIONS AT MOUNT SINAI MEDICAL CENTER
03.2012 - 02.2015
- Screened patients for Medicaid and Social Security eligibility in hospital setting (medical and psychiatric floors)
- Organized hospital administration files for government filing and OSHA/HIPPA audits
- Weekly reviewed high balance accounts in order to justify lengthy hospital admissions
- Reported on high risk accounts and kept management and healthcare providers informed
- Worked in conjunction with primary care and specialist physicians, case managers, nurses, social workers as well as patients and patient family members
- Processed State and Government applications with a 95% approval rate
- Assisted in preparation of medical records to release to other medical facilities requesting for patient history and information
- Analyzed complex medical records in order to determine patient's eligibility for Medicaid/ Social Security benefits based on newly diagnosed or preexisting conditions
Education
Bachelor of Arts - Psychology
Florida International University
Miami, FLSkills
- Bilingual & Fluent (English/Spanish)
- Strategic Thinking
- Time Management and Planning
- Utilization Management
- Problem solving and conflict resolution
- Ability to assess safety risks and Crisis Intervention
- Excellent Interpersonal & Communication skills
- Knowledge of medical and psychiatric terminology
- Experienced in working with patients in geriatric and mental health population
- Advanced Proficiency with MS Office
- Strong adherence to HIPPA guidelines
Certification
- Certification in the DOEA 701B Assessment tool
- CPR Certification
References
References available upon request
Timeline
Long Term Care Case Manager for Geriatric and Psychiatric Population
FLORIDA CARE MANAGEMENT SERVICES AGENCY
08.2018 - Current
Patient Care Coordinator
SOUTH FLORIDA PULMONARY CARE, INC.
01.2017 - 08.2018
Behavioral Health Specialist
MOLINA HEALTHCARE, INC.
08.2015 - 11.2017
Behavioral Case Manager (SED)
PSYCHSOLUTIONS, INC.
03.2015 - 07.2015
Medicaid Eligibility Specialist
MEDASSIST SOLUTIONS AT MOUNT SINAI MEDICAL CENTER
03.2012 - 02.2015
Bachelor of Arts - Psychology
Florida International University
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