BERNICE ENCARNACION, RN CCM
Stratford,CT
Overview
15
15
years of professional experience
Work History
UM Care Review Clinician
Molina Health Care
12.2023 - Current
- Assess services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.
- Analyze clinical service requests from members or providers against evidence based clinical guidelines.
- Identify appropriate benefits, eligibility and expected length of stay for requested treatments and/or procedures.
- Processes requests within required timelines.
- Refer appropriate cases to Medical Directors and presents them in consistent and efficient manner.
- Make appropriate referrals to other clinical programs.
- Collaborate with multidisciplinary teams to promote Molina Care Model.
- Adhere to UM policies and procedures.
IV Therapy Nurse
Beyond IV Therapy
08.2022 - 12.2023
- IV MOBILE RN- BEYOND IV THERAPY
- Conduct Good Faith Exams, obtain vital signs and collaborate with Medical Director prior to administering IV Treatment, Botox injectables and Dermal Fillers
- Educate clients procedures, benefits and potential interactions of different vitamin infusion and medications
- Deliver treatments and intramuscular per protocol to maintain effective client protection
- Visit clients at various locations in Connecticut to provide professional and high-quality IV infusion
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms
UM CARE MANAGER
Emblem Health
09.2020 - 09.2022
- Utilizes InterQual Criteria, CMS Guidelines, medical and administrative policies to evaluate medical necessity for 12-18 pre-service reviews
- Identifies members at risk and refers for Care management and/or disease management as needed
- Assesses
- Supports the department's quality of care and cost containment
- Provides utilization management as needed to ensure coordination of health care delivery.
UTILIZATION MANAGEMENT NURSE CONSULTANT
Aetna
05.2017 - 09.2020
- Perform Utilization Management and Case Management activities
- Conduct Medicare and Commercial LTACH, Acute Rehab and Subacute initial request and concurrent review
- Review charts follow diagnosis clinical pathways of established CMS and MCG criteria for pre-authorizations and continued stay
- Work collaboratively with Nurses, Physicians, intra-hospital departments, social services to assess and orchestrate acute and post-acute hospital patient needs and present in case rounds
UTILIZATION RN REVIEWER
AFFINITY HEALTH
03.2014 - 03.2017
- Review Medicare Inpatient/outpatient request based on CMS and MCG Criteria
- Supervise and monitor member’s plan of care to
- Coordinate community resources post discharge
- Educate patients on the disease process, follow up and preventative care
- Coordinate care with behavioral health service and interdisciplinary team of social workers, pharmacists and nutritionists
Registered Nurse, Home Health Care
First Care Of New York
07.2012 - 03.2014
- Scheduling 24 or more home visits per week including admission, quarterly and post hospitalization assessments
- Review discharge documents and educate as needed on new medications and important instruction.
Registered Nurse Assessment Coordinator
Accent Care Of NY
10.2012 - 11.2013
- Scheduling 8-10 intake visits per week including conducting field face to face assessment
- UAS assessments for Bronx, NYC Brooklyn and Queens to determine services for
- Members
Emergency Room Staff Nurse
MONTEFIORE NORTH
06.2012 - 10.2012
- Readily develop rapport with patients, staff and physicians, assigned to provide care for up to 10 patients
- Schedule patient’s admissions/discharges, perform clinical tasks according to hospital policies
Registered Nurse, Home Health Care
HCS Of NY
04.2009 - 06.2012
- Scheduling 8-10 home visits per week including admission, supervision home health aides in the homes of the patient
- Administering patient’s medications and medication pre-pour
Emergency Room Staff Nurse
EMERGENCY, WESTCHESTER SQUARE, HOSPITAL
10.2009 - 06.2011
- Develop and implement patient care for 8+ patients in the ED
- Maintain electronic patient charts, confidential files and continuous nursing
- Assessment
Education
Bachelor of Science - Nursing
WESTERN GOVERNORS UNIVERSITY
12.2025
Associate of Science - Nursing
Bronx Community College of The City University of New York
The Bronx, NY2009
Timeline
UM Care Review Clinician
Molina Health Care
12.2023 - Current
IV Therapy Nurse
Beyond IV Therapy
08.2022 - 12.2023
UM CARE MANAGER
Emblem Health
09.2020 - 09.2022
UTILIZATION MANAGEMENT NURSE CONSULTANT
Aetna
05.2017 - 09.2020
UTILIZATION RN REVIEWER
AFFINITY HEALTH
03.2014 - 03.2017
Registered Nurse Assessment Coordinator
Accent Care Of NY
10.2012 - 11.2013
Registered Nurse, Home Health Care
First Care Of New York
07.2012 - 03.2014
Emergency Room Staff Nurse
MONTEFIORE NORTH
06.2012 - 10.2012
Emergency Room Staff Nurse
EMERGENCY, WESTCHESTER SQUARE, HOSPITAL
10.2009 - 06.2011
Registered Nurse, Home Health Care
HCS Of NY
04.2009 - 06.2012
Bachelor of Science - Nursing
WESTERN GOVERNORS UNIVERSITY
Associate of Science - Nursing
Bronx Community College of The City University of New York
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