BEATRIZ GALIANO
Miami,FL
Summary
Certified Case Manager (CCM) with extensive experience providing and managing complex case management to Medicare Advantage managed care, Fully Integrated Special Needs Plan (D-SNP), Medicaid Long Term Care and Commercial health plan enrollees. Experienced in helping nursing, non-clinical staff and care partners solve complex care coordination issues, in achieving positive outcomes for high-risk patient populations and in significantly improving resource utilization. Superior work ethic with top strengths in problem solving and complex care coordination involving interdisciplinary healthcare provider teams.
Overview
27
27
years of professional experience
Work History
Patient Care Manager
Healthfirst
05.2023 - Current
- Collaborated with physicians and other healthcare professionals to develop comprehensive care plans for enrollees.
- Customized care plans, working with members and families to assess and meet individual needs.
- Consulted with supervisors to assess cases and plan strategies for enhancing care.
- Participated in team meetings and trainings to stay updated on best practices and new developments in care management.
- Communicated with healthcare providers to facilitate continuity of care.
- Educated clients and families on community resources, treatment options and health care services to better manage conditions.
- Developed strong interdisciplinary team collaboration, resulting in better patient outcomes.
- Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for members.
- Established and maintained relationships with clients, families and community partners to coordinate services to meet client's needs.
- Maintained network of community resources to provide most comprehensive support services possible to clients.
- Maintained accurate documentation of patient interactions in electronic medical records systems.
- Used strong analytical and problem-solving skills to develop effective solutions for challenging situations.
- Skilled at working independently and collaboratively in a team environment.
Manager, Clinical Performance: Supervisor, Complex Care Nurse
Bright Health Management, Inc.
10.2021 - 01.2023
- Onboard, coach and evaluate clinical staff to improve performance in the areas of clinical care coordination and resource utilization, primarily for complex and high-risk Medicare Advantage population including Special Needs Plan (SNP) members in Florida, New York, Colorado and Arizona
- Serve as mentor for new nurse care managers in proper techniques, care standards, operational procedures and safety protocols
- Partner with patients, medical and care management leadership, primary care physicians, specialists, social workers and other nurse case managers to develop and implement individualized care plans and document patient interactions and interventions in electronic charting systems
- Identify care needs of individual patients and coordinate response and/or create an individualized care plan based on physician/medical provider advice, social determinants of health, insurance limitations and procedural costs
- Consult with interdisciplinary care team to devise and manage ongoing care plans for at-risk patients
- Help patients receive appropriate, high-quality care with reasonable results
- Develop policies, standard operating procedures, processes and job aids to improve patient/member outcomes and regulatory compliance
- Prepare for and participate in audits
- Compile data highlighting key metrics to report information, determine trends and identify methods for improving resource utilization.
Nurse Case Manager
UnitedHealth Group
12.2015 - 10.2021
- Population health management of caseload of 50 to 100 high risk and special needs population members in complex care, high risk transition and longitudinal programs
- Served as educator, mentor and subject matter expert for other case managers in areas of Special Needs Plan (SNP) and Complex Care patient management
- Developed and modified patient care plans and assist interdisciplinary team in identifying client needs and goals to determine priorities of care
- Analyzed patient responses to medications, therapies and variances in plans of care
- Collaborated with primary care providers, specialists, external business partners (such as home health, palliative care and hospice providers), social workers and other care team members to ensure optimal resource utilization and positive patient outcome
- Participated in annual audit in 2020 as presenter for all South Florida markets with positive end result
- Provided innovative telehealth process idea in April 2020 providing access to care for technologically challenged homebound patients with more than one hundred fifty thousand medical provider visits successfully completed using this process to date.
Care Coordinator
Preferred Medical Plan
09.2006 - 12.2015
- Conducted onsite hospital hospitalization reviews at all Baptist Health South Florida hospitals in Miami-Dade County, Jackson Memorial Hospital, Kendall Regional Medical Center, Miami Children's Hospital, Mercy Hospital, Coral Gables Hospital, Palmetto General Hospital and Larkin Hospital
- Served as liaison between hospitals, insurance company and providers
- Participated in quarterly strategic planning meetings between contracted physician groups and insurance executives
- Coordinated inpatient and outpatient services, coordinated hospital transfers, conducted medical reviews of outpatient member referrals, provided telephonic case management and disease management.
Staff Registered Nurse
Baptist Health South Florida
09.1996 - 09.2006
- Worked within interdisciplinary health care team to develop, implement and make adjustments to patient care plans, individualizing strategies and methods to improve health and meet recovery goals
- Home Health Hospital Liaison serving as an expert transition of care coordinator and consultant
- Home health skilled nurse - Performed various nursing interventions such as wound dressing, vital sign monitoring and specimen collection
- Gathered patient health data through interviews and observation, documenting data in electronic records
- Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches.
Education
Master of Science - Nursing
Florida International University
Miami, FL12.2010
Bachelor of Science - Nursing
Florida International University
Miami, FL04.2008
Diploma in Nursing - Nursing
Jackson Memorial Hospital School of Nursing
Miami, FL06.1991
Skills
- RN Florida compact multistate license
- RN New York state license
- Master of Science in Nursing (MSN)
- Certified Case Manager (CCM) since 2010
- Bilingual: Fluent in Spanish
Personal Information
Title: MSN, RN, CCM
Timeline
Patient Care Manager
Healthfirst
05.2023 - Current
Manager, Clinical Performance: Supervisor, Complex Care Nurse
Bright Health Management, Inc.
10.2021 - 01.2023
Nurse Case Manager
UnitedHealth Group
12.2015 - 10.2021
Care Coordinator
Preferred Medical Plan
09.2006 - 12.2015
Staff Registered Nurse
Baptist Health South Florida
09.1996 - 09.2006
Master of Science - Nursing
Florida International University
Bachelor of Science - Nursing
Florida International University
Diploma in Nursing - Nursing
Jackson Memorial Hospital School of Nursing
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