ALINA GOMEZ RN, BSN
Tampa,FL
Summary
Experienced Case Manager skilled in managing high caseloads and delivering top-quality care. Excels in high-pressure settings, consistently identifying optimal resources and actions to meet patient needs and enhance quality of life.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Case Manager I
Centene
2022.06 - Current
- Assess the member's current health status, resource utilization, past and present treatment plan and services, prognosis, short and long term goals, treatment and provider options
- Utilize assessment skills and discretionary judgment to develop plan of care based upon assessment with specific objectives, goals and interventions designed to meet member's needs and promote desired outcomes
- Coordinate services between Primary Care Physician (PCP), specialists, medical providers, and non-medical staff as necessary to meet the complete medical socio economic needs of clients
- Provide patient and provider education
- Facilitate member access to community based services
- Actively participate in integrated team care management rounds
- Perform duties independently, demonstrating advanced understanding of complex care management principles.
- Maintained accurate documentation on all cases, ensuring compliance with regulations and confidentiality requirements.
- Conducted thorough assessments of clients'' situations, identifying issues, goals, and necessary interventions.
- Monitored ongoing cases closely, adjusting case management strategies as needed based on evolving circumstances or new information.
- Educated clients on available programs, benefits, and services, empowering them to make informed decisions about their care needs.
- Enhanced communication between clients and providers through consistent follow-ups and progress updates.
- Achieved positive client outcomes by developing and implementing comprehensive case management plans.
- Provided crisis intervention support for clients experiencing emergencies, using appropriate techniques to de-escalate situations safely.
- Advocated for client rights when interacting with external agencies or institutions, ensuring fair treatment at all times.
Corporate Auditor/Utilization Mgmt.
ActiKare In Home Medical
2021.03 - 2022.12
- Worked entirely remote from home, utilization of various computer systems and zoom without difficulty
- Assessed areas the owner/CEO wanted to check for utilization, staffing, pay rates, and outcomes
- Wrote policies and procedures after assessed areas, retrained or restaffed divisions successfully, ensuring department success
- Assessed and audited the company Account Receivable and payroll systems, successfully obtained full reimbursement for claims from 2018 to current
- These were billing thru various HMO, Medicaid, VA Tricare, private pay payers
- Assessed and redeveloped the entire corporate call center, auditing calls and providing live QA feedback as well as exceeding sales goals for adding new patients thru out the companies 90+ franchises all over the US
- Calls per day were inbound and outbound over 600 per day on average
- Performed mock audits at agencies varied locations and states to ensure compliance
- Performed home visits as an RN DON for the local agencies to initiate care, manage complaints and clinical care concerns and need for follow up
- Trained the new franchisees with the software system, Smartcare, and the state regulations to ensure successful licensure and start up
- Exceeded all goals, received my bonuses as eligible and provided my team any requested on projects not assigned to me but where I could be of assistance
- Left on good terms.
- Assisted in the development of annual audit plans, ensuring thorough coverage of key business areas.
- Evaluated the effectiveness of implemented corrective actions, ensuring alignment with regulatory requirements and best practices.
- Improved internal control systems by conducting comprehensive audits and risk assessments.
- Participated in cross-functional teams to address complex business issues, providing expert guidance on internal audit matters.
- Developed strong working relationships with external auditors, facilitating efficient communication during annual reviews.
- Utilized data analytics tools to identify patterns and anomalies within financial records, strengthening overall audit quality.
- Maintained up-to-date knowledge of industry trends and changes in regulations, applying insights to enhance audit methodologies.
- Presented findings from completed audits to senior management team members, offering actionable insights for strategic decision-making purposes.
- Identified potential areas of operational improvement through detailed financial analysis and reporting.
- Streamlined documentation processes for improved record-keeping accuracy and accessibility during audits reviews.
- Collaborated with management to develop action plans for addressing identified weaknesses and deficiencies in internal controls.
- Conducted fraud investigations as needed, uncovering instances of misconduct or noncompliance within the organization.
- Reduced financial risks, streamlining processes to optimize efficiency in auditing procedures.
Surveyor- Private Duty and Medicare/Medicaid Home Health
ACHC
2016.01 - 2018.01
- Managed schedule independently performing surveys for home care organizations throughout the United States
- Effectively time management to complete a time sensitive objective while quickly building trust and rapport to engage client and facilitate understanding of methods to incorporate to ensure success
- Applied systems analysis skills and inductive reasoning skills to determine health care organizations' degree of compliance with applicable standards and functionality of care delivery systems
- Engaged health care organization staff in interactive dialogues on standards-based issues in health care in order to assess compliance and to identify opportunities for improving compliance
- Prepared management reports that clearly link individual standards deficiencies with potential systems vulnerabilities and related organization risk points
- Effectively communicated this information to health care organization leadership in a constructive and collegial style.
- Gathered, organized and modeled data for reports and presentations.
- Performed accurate documentation of patient assessments, interventions, and outcomes in compliance with regulatory standards.
- Communicated with production team members about quality issues.
- Maintained accurate records of inspection findings, facilitating data-driven decision-making for process improvements.
- Collaborated with cross-functional teams for the successful implementation of new compliance initiatives.
- Monitored adherence to industry regulations, ensuring timely reporting of any discrepancies or violations.
- Prepared documentation and records for upcoming audits and inspections.
- Improved company''s risk management strategy by identifying, assessing, and mitigating potential risks related to noncompliance.
- Developed improvement and corrective action plans to bring operations in line with requirements.
- Assisted in the development of a comprehensive risk assessment framework for evaluating potential threats to organizational compliance systems.
VP Operations:Administrator/Director of Clinical Practice and Founder
Reliant Home Health Care LLC
2011.01 - 2016.01
- Proud co-owner of a self-financed, financially sound, no investors CHAP Medicare Provider for skilled Home Health Care needs for the Pinellas and Pasco counties; Hillsborough County separate Medicare Provider number
- Business model will be shaped and developed with a physicians practice needs in mind, focusing on ACO outcomes and recognition for quality care
- Business acquired by Pinnacle Home Health Care in Florida as of November 2015
- Regional Administration with acquisition company, Pinnacle Home Care
- Received 5 STAR rating for the Pinellas office year one based on HHC Compare.
- Hired and managed employees to maximize productivity while training staff on best practices and protocols.i
- Cultivated a high-performance culture within the organization by setting clear expectations for employees at all levels, providing regular feedback, and recognizing achievement.
- Hired and managed employees to maximize productivity while training staff on best practices and protocols.
- Championed change management initiatives within the organization to ensure smooth transitions during periods of growth or restructuring.
- Negotiated favorable contracts with vendors, securing advantageous terms for the company while maintaining strong professional relationships.
- Developed and executed targeted business development initiatives, leading to an expansion of the company''s client base.
- Increased company growth through collaboration with sales and marketing departments.
Director of Professional Services
Brookdale Senior Living – Innovative Senior Care
2011.01 - 2013.08
- Clinical oversight, financial, team building, AHCA and Medicare compliance, census development within community and ILF/ALF settings
- Multiple corporate awards for our Network and exceed NOI, all budget targets for all 10 facilities and community-based patients within Network
- Largest Network in the ISC division
- Census of 260+, 90% Medicare
- Trainer for Florida Director of Professional Services and Corporate Liaison for special projects involving pay structure rollout, software implementation.
- Reduced operational costs by identifying inefficiencies and implementing cost-effective solutions for service delivery.
- Streamlined internal communication channels to improve collaboration between departments, enhancing overall organizational effectiveness.
- Collaborated with cross-functional teams to develop tailored solutions for complex client challenges, increasing customer loyalty and driving repeat business.
- Oversaw implementation and development of projects, minimizing operational deficiencies and driving customer satisfaction.
- Cultivated strong relationships with industry thought leaders, expanding the company''s network and creating new business opportunities.
- Managed professional service team, celebrating milestones, supporting sales operations and determining future goals.
Regional Administrator/Chief Nursing Officer
Vitalcare Home Health
2009.01 - 2011.01
- Responsible for total branch management including sales, personnel, recruiting, budgeting and P/L
- Started three agencies with successful state and JCAHO deficiency free surveys
- Established an ongoing training program for new staff members
- Developed sales strategies to ensure achievement of all business plan objectives
- Assist with regional guidance for compliance, regulatory, supervision both clinically and agency wide focus
- Responsible for direction of all home health clinical services
- Establishes, implements and evaluates goals for providing home health services that support the mission and philosophy of the Agency
- Concurrently assisted in set up of another company in Sarasota, FL and was sole contact for all business aspects including JCAHO early survey and deemed status.
- Successfully transitioned legacy systems into modernized platforms with minimal disruption to ongoing operations.
- Spearheaded regional initiatives to achieve company-wide goals and improve overall performance.
- Established strong relationships between regional offices, fostering collaboration and information sharing.
- Ensured compliance with company policies, industry regulations, and legal requirements across all regional operations.
- Fostered a positive work environment by cultivating a supportive atmosphere that encouraged professional growth.
- Delivered timely reports on regional activities, highlighting achievements, challenges, and opportunities for growth.
Administrator/Director of Clinical Services
Advanced Homecare Inc
2007.01 - 2009.01
- Responsible for total branch management including sales, personnel, recruiting, budgeting and P/L
- Started Agency with successful state, ACHC and Medicare deficiency free surveys
- Established an ongoing training program for new staff members
- Developed sales strategies to ensure achievement of all business plan objectives
- Responsible for direction of all home health clinical services
- Establishes, implements and evaluates goals for providing home health services that support the mission and philosophy of the Agency
- Demonstrated ability to lead start up agency with supervision and direct clinical and administrative personnel
- Census rapid growth from zero to over 300 Medicare only patient base in less than 18 months
- Company acquired
- Relocated with same owners to Tampa, Florida to repeat our synergic success as a minority partner, earning stock within the agency upon acquisition.
- Handled sensitive information discreetly, maintaining strict confidentiality at all times as required by company policy or legal regulations.
- Maintained personnel records and updated internal databases to support document management.
- Organized workflow and delegated tasks effectively to ensure timely project completion without compromising quality.
- Managed office inventory levels, ensuring adequate supplies were available while minimizing waste and unnecessary spending.
- Supervised administrative support staff members, offering guidance, feedback, and mentorship that contributed to their professional growth and development.
New Business Development Clinical Liaison
Welcome Home Care
2006.01 - 2007.01
- Responsible for effective intake, education, and coordination of home health services in the community and between facilities and the agency
- Managed a team of physician assistants, clinical team and clerical support
- Promotes and maintains the image of the agency in the area served according to agency mission, philosophy and all regulatory standards
- Took over large geographical location in decline and continues to exceed sales quota
- Awarded highest admissions goal for month of last quarter
- Secured new areas of business including health fairs, physicians, and assisted living facilities, utilizing new business line of visiting physicians
- Start up employee for Visiting Physician practice including software applications/training.
- Educated health care professionals on ways to humanize patients' experiences.
- Enriched patient experience by coordinating multidisciplinary team meetings to review individualized goals and progress updates regularly.
- Supported evidence-based practice implementation within clinical teams through ongoing research review and dissemination of current best practices.
- Assisted in staff education and development by sharing clinical expertise in relevant areas such as wound care, respiratory therapy, or disease management.
- Cultivated productive relationships with referral sources, leading to increased admissions for the facility.
- Streamlined the referral process for smoother patient transitions into post-acute care settings through meticulous documentation and timely communication.
- Maintained compliance with all federal/state regulations governing skilled nursing and rehabilitation services, ensuring high-quality service delivery for all patients.
- Served as a liaison between patients and their insurance providers, advocating for coverage of necessary treatments and services.
Director of Clinical Services/Corporate Compliance Officer
Apex Home Health Services
2004.01 - 2006.01
- Held Director of Clinical Services position with multiple deficiency free surveys and promoted after 18 months to corporate position
- Defines, plans, implements, and evaluates performance improvement by identifying key areas to improve and plans to accomplish Agency goals; develops and implements process improvement activities with appropriate data collection, aggregation, and analysis, taking action and reporting results according to Agency's PI plan
- Surpassed all goals set for 1 year of employment
- Supervision of clinical staff monitoring patient outcomes, patient needs and maintaining detailed documentation for agency, physician updates and Medicare guidelines
- Revised policies and procedures for Medicare agency
- Ensures compliance with professional standards and regulations
- Active primary liaison with Florida Medical Quality Assurance Initiative (FMQAI)
- Maintained clinical skills and achieved OASIS certification while enrolled in Legal Nurse Consulting certification to augment proficiency in current job responsibilities.
- Improved interdisciplinary collaboration, fostering strong working relationships among medical professionals for optimal patient outcomes.
- Championed best practice sharing among departments, resulting in more consistent execution of patient care processes and improved outcomes.
Education
Bachelor of Science - Nursing Assistance
University of North Florida
Jacksonville, FL12.1999
Skills
- Problem-Solving
- Case Management
- Organization and Multitasking
- Care Coordination and Advocacy
- Case Documentation and Reporting
- Interpersonal Skills
Educationcertifications
- University of Central Florida, Jacksonville, FL, Legal Nurse Consultant Certification
- CAHSAH, Home Care Administrator Certification (Stage 1)
- CAHSAH, Home Care Executive Certification (Advanced Stage 2)
- University of North Florida, Jacksonville, FL, Bachelor of Science Nursing, Summa Cum Laude
- Florida Community College of Jacksonville, Associate Degree/nursing, Deans List
- Florida State University, Tallahassee, FL, Associate of Arts
Certification
RN 9165143, CLEAR/Active, Multi-state, 04/30/25, 02/02/00
Affiliations
- Florida State Alumni Association
- Phi Kappa Phi Fraternity
- Phi Mu Fraternity, Alpha Epsilon Chapter
- Golden Key Honor Society
- Who's Who among Students in American Colleges
- Florida Nurses Association
- NCAA Scholarship Awarded Freshman - Bowling
- Florida Latino Honored Female
Qualifications Summary
Results oriented, goal driven, self-motivated healthcare professional with a proven track record of quality of care, case management and utilization review within the ever changing landscape of today coupled with an understanding of business development and revenue growth...while giving consistent, quality care to every patient., Highly skilled leader versed in legal and ethics management., Analytical, decisive in problem solving, resource for other staff as a leader and loyalty to the culture and colleagues to succeed., Hands on clinical excellence and supervisory capacity to a variety of patient needs and professional staff., Well versed in AHCA State of Florida, Medicare regulation, ACHC, JCAHO and CHAP policies and procedures, ICD10 knowledge, Windows, Excel, Outlook, Teams, and various other high level programs., Revenue focused and cognizant of all line items with department financials, Computer literate, quick study and strong written and verbal communication., Experience with utilization review, case management, triage care needs, Workman’s Comp, private payer, Medicare, Medicaid and Tricare experience with all management roles., Proficient in multiple EMR systems (HCHB, Axxess and education systems as well as implementation of such systems for organization of over 1,500 FTE clinical staff.
Timeline
Case Manager I
Centene
2022.06 - Current
Corporate Auditor/Utilization Mgmt.
ActiKare In Home Medical
2021.03 - 2022.12
Surveyor- Private Duty and Medicare/Medicaid Home Health
ACHC
2016.01 - 2018.01
VP Operations:Administrator/Director of Clinical Practice and Founder
Reliant Home Health Care LLC
2011.01 - 2016.01
Director of Professional Services
Brookdale Senior Living – Innovative Senior Care
2011.01 - 2013.08
Regional Administrator/Chief Nursing Officer
Vitalcare Home Health
2009.01 - 2011.01
Administrator/Director of Clinical Services
Advanced Homecare Inc
2007.01 - 2009.01
New Business Development Clinical Liaison
Welcome Home Care
2006.01 - 2007.01
Director of Clinical Services/Corporate Compliance Officer
Apex Home Health Services
2004.01 - 2006.01
Bachelor of Science - Nursing Assistance
University of North Florida
RN 9165143, CLEAR/Active, Multi-state, 04/30/25, 02/02/00
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