Byron Gonzalez
Hialeah,FL
Summary
Experienced Licensed RN dedicated to providing exceptional patient care. Strong focus on interpersonal skills and making a positive impact in the healthcare field. Possesses a sense of purpose and continually seeks to expand nursing skillset. Authorized to work in the US for any employer, ensuring career flexibility and adaptability.
Overview
21
21
years of professional experience
1
1
Certification
Work History
Concurrent Review Nurse
Leon Medical Centers
10.2022 - Current
- Develops, educates, and manages clinical and non-clinical staff within the guidelines of Leon Health’s policies and procedures to assure competencies which are appropriate to accomplish duties and responsibilities productively and efficiently
- Responsible for monitoring incoming calls and written inquiries from members, providers, and in-house departments
- Monitors, evaluates, and prioritizes the quality, timeliness, and accuracy of prior authorization reviews
- Responsible for the data entry of service requests/decisions into the plan’s system, when applicable, in accordance with regulatory guidelines and plan policies
- Reviews clinical documentation for pre-certifications and continued (concurrent) reviews prior to the review
- Conducts on site and/or telephonic reviews for appropriateness of treatment setting on inpatient/outpatient admissions and continued (concurrent) stays utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products
- Conducts Medical and BH reviews prior and post authorization service requests utilizing the applicable medical policy, CMS guidelines, evidenced based industry standards and managed care products
- Provides authorization to providers, facilities, and members (when applicable) for inpatient admission, outpatient precertification, prior authorization, and post service requests
- Refers cases requiring further clinical review to a Medical Director or Behavior Health Practitioner as appropriate
- Provides complete and accurate documentation specifying rational for approvals
- Processes Medical Director or Behavior Health Practitioner denials in accordance with regulatory guidelines and plan policies
- Updates census reports, notes, and all authorization documentation daily including running a daily admissions and discharge report
- Collaborate with clinicians and/or providers to obtain necessary clinical documentation for medical necessity reviews
- Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning
- Facilitates member care transition through the healthcare continuum by collaborating with facilities and Care Management
- Monitors and evaluates the quality, timeliness, and accuracy of prior authorization reviews
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards
- Assists in peer training as needed
- Participates in Quality Improvement and Risk Management activities as requested
- Participates in training and in-service education as required
- Complies with Leon Health’s policies and procedures and maintains confidentiality of patient’s medical records in accordance with state and federal laws
- Maintains open channels of communication with other company departments
- Answers all inquiries in a professional and courteous manner
- Performs other duties as assigned
Registered Nurse (RN)
Unity rehabilitation
03.2022 - 03.2023
- Provides plan care for all resident attending to
- Documents the patient care activities performed on the unit
- Must document changes and follow up on condition
- Organizes, cleans and maintains the patient/resident units
- Ensures that resident’s/patient’s rights are adhered to
- Participates in departmental activities and follows established guidelines
- Perform clerical functions for the nursing unit
- Performs related duties as required
- Collected and interpreted patient data
- Facilitated the plan of care
- Formulated and evaluated health care plans
- Administered medication and treatments through Point Click Care
- Delivered patient education
Prior Authorization Pharmacy Technician
Molina Healthcare Inc
06.2017 - 09.2022
- Perform initial receipt and review of non-formulary or prior authorization requests against plan approved criteria
- Requests additional information from providers as needed in order to properly evaluate the request
- Accurately enter on-line approvals or denials of requests such as HCPS J-Code requests, regular pharmacy PA requests in in house pharmacy system called CAS
- Authorized to make and carry out simple prior authorization requests within established policies and procedures
- Participate in the development /administration of programs designed to enhance the utilization of targeted drugs and the identification of cost saving pharmacy practices
- Identifies and reports departmental operational issues and resource needs to appropriate management
- Assist Molina Member Services, pharmacies, and health plan providers in resolving member prescription claim, prior authorization, or pharmacy services access issues
- Articulates Pharmacy Management policies and procedures to pharmacy/health plan providers, other Molina staff and others as needed
- Review HCPC (J-Codes) prior authorization requests utilizing clinical notes submitted by provider which then is sent a clinical pharmacist for review
- Contact provider to obtain missing request information such as missing dosage, frequency, date of service or clinical notes for HCPC (J-Codes) prior authorizations
- Calculate the total units and chemo cycles based on the time span for each J-Code request once pharmacists have approved the request
- Enter the approval information (member information, total units, total cycles, date of service dates) into in-house medical insurance billing plan system called QNXT
Order Entry Technician
ProcareRx
10.2016 - 06.2017
- Create and enter new prescription and refill orders for patients
- Submit insurance claims to obtain copay
- Enter credit card information to process order payment
- Fill incoming orders via Pharmacy filing system
- Contact doctors when needed to verify prescription or patient information
- Type and translate prescription information and enter into Pharmacy inhouse system
- Enters patient, doctor, insurance and prescription information quickly and accurately into the computer system and processes claims for adjudication
- Interprets medical abbreviations (SIG Codes)
- Reads and reviews prescriptions, troubleshoots to obtain missing information, performs computations such as addition, subtraction, multiplication
- Works closely with billing representative to manage and process pending order claims
Senior Training Associate(pharmacy)
OPTUM/UnitedHealth Group/Briova Specialty
12.2014 - 08.2016
- Train new and existing staff on new processes
- Collaborate with curriculum design team to adjust training content
- Partner with operations leaders regarding their priorities
- Lead deployment projects for national business initiatives
- Serve as SME(subjects matter expert) on project meetings and implementations by leading curriculum revisions and by serving as liaison with Operations on training questions
- Interview and consult with key business leaders and subject matter experts (SMEs)
- Assess and interpret customer needs using pertinent facts and data to solve a range of complex problems
- Maintain preparedness to deploy multiple training curriculums at all times
- Create project plan and ensure overall project is delivered on schedule and within scope
- Communicate effectively to provide project status updates to supervisor, requester and other business leaders
- Monitor and evaluate the impact of training and communications
- Identify ongoing and re-training needs and recommend solutions
- Participate in internal continuous improvement efforts by offering ideas and creative solutions to improve policies, processes and tools
- Supervise or mentor training staff
- Schedule and facilitate refresher training courses and deliver training material
Tech Translation Technician(Data Entry)
Catamaran Home Delivery
05.2012 - 12.2014
- Type incoming prescription orders
- Select correct patient information
- Input correct drug and dosage form
- Calculate and optimize accurate quantity and day supply
- Select precise prescriber and prescriber information
- Type exact directions for each prescription
- Update and add insurance information
- Proof read each prescription to adhere and meet 100% quality
Order Entry Technician
Catamaran Home Delivery
05.2012 - 12.2014
- Create new incoming patient orders
- Input and elect correct patient data and specifications(shipping address, patient notes)
- Add patient accounts like credit card, checks, coupons for payments
- Research for previous shipping data to adhere to quality procedures
- Create and process urgent incoming orders for our members
Inventory Specialist
Catamaran Home Delivery
05.2012 - 12.2014
- Enter new drug into Pharmacy system
- Update and replace drug NDC numbers into the system
- Check inventory for Out of Stock drugs to reorder
- Check patient account balance and call patients if max credit balance has surpassed amount allowed per company restrictions and contact patients
Task Force Technician
Catamaran Home Delivery
05.2012 - 12.2014
- Process urgent orders
- Type highly controlled prescription drugs
- Monitor each incoming order for fast processing
- Calculate exact quantity and day supply for each highly controlled medication
Failed Claims Technican
Catamaran Home Delivery
05.2012 - 12.2014
- Resolve rejected insurance claims
- Update insurance coverage and information in order to process orders
- Add missing insurance information (bin number, group, carrier, pcn) for certain insurance companies
- Log rejection claims like drug not covered, otc not covered, refill too soon and any other typed of information that is needed to be logged
- Develop PA requests for cost amount exceeded orders for certain drugs
- Place PA overrides into Rxclaim system data in order to process approved drugs
Data Entry Specialist
Walgreens Co.
05.2009 - 05.2012
- Read and verify incoming prescriptions
- Input prescriber information, date, drug name and directions and refills
- Input correct days of supply for each prescription
- Calculate dosage and correct quantity
- Dispatcher to assist co-workers who need help in a prescription
- Solve insurance issues when a drug is not covered, prescriber not covered or
- When patient does not have insurance coverage
- Contact insurance plan like Aetna, Cigna, Humana when a patient needs a vacation override, change in drug dosage or obtain other type of insurance coverage if patient has no coverage
- Contact Prescriber offices for Prior Authorizations, missing or invalid prescriber information (prescriber state licenses)
- Contact patients to notify that their insurance coverage is terminated and to obtain information if they have other type of primary coverage and notify patient that their drug is not covered by the insurance
Resolution Specialist
Walgreens Co.
05.2009 - 05.2012
- Read and verify incoming prescriptions
- Input prescriber information, date, drug name and directions and refills
- Input correct days of supply for each prescription
- Calculate dosage and correct quantity
- Dispatcher to assist co-workers who need help in a prescription
- Solve insurance issues when a drug is not covered, prescriber not covered or
- When patient does not have insurance coverage
- Contact insurance plan like Aetna, Cigna, Humana when a patient needs a vacation override, change in drug dosage or obtain other type of insurance coverage if patient has no coverage
- Contact Prescriber offices for Prior Authorizations, missing or invalid prescriber information (prescriber state licenses)
- Contact patients to notify that their insurance coverage is terminated and to obtain information if they have other type of primary coverage and notify patient that their drug is not covered by the insurance
Certified Pharmacy Technician
Walgreens
12.2005 - 04.2009
- Communicate with doctors and hospitals on a day to day basis for refill authorization, and to verify prescriptions
- Resolve and handle various types of insurance problems(Humana, Cigna, Aetna)
- Type new incoming prescriptions, fill prescriptions, and let the Pharmacist verify the filled prescription
- Handel and mix certain types of medications( Antibiotics, creams, etc)
Recreational Leader
City Of Hialeah Parks AND RECREATION
04.2004 - 11.2005
- Educate kids with disabilities with the supervision of a certified Education teacher
- Coach them and prepare them for various types of sports
- Supervise them in different types of activities
- Organize special events and field trips
Education
Associate's degree - Nursing
Miami Regional University
Hialeah, FL04.2020
High School Diploma - undefined
Barbara Goleman Senior High
Miami Lakes, FL12.2007
Associate's degree - Pharmacy
Miami Dade College
Miami, FL03.2006
Diploma - undefined
Miami Lakes Education Center
Miami Lakes, FL01.2003
Skills
- Proficient in EHR software
- Experienced with Excel
- Healthcare utilization management
- Knowledgeable in clinical terminology
- Medication delivery
- Insurance eligibility verification
- Patient data management
- Electronic medical records management
- ICD-10 coding expertise
- Epic knowledge
- Effective communication
- Medical coding proficiency
- Pharmacy technician expertise
- Clinical pharmacy expertise
- Windows operating system
- Clinical documentation
- Medicare knowledge
- Accurate order entry
- Clinical utilization review
- ICD-9 coding
- Quality patient care
- Proficient in Outlook
- Data organization
- Curriculum development
- Effective time management
- Clinical documentation enhancement
- Patient care
- Continuous patient observation
- Collaborative negotiation approach
- Process optimization
- Comprehensive documentation analysis
Certification
- Registered Nurse (RN) August 2020 to Present Florida State Board of Nursing License RN 9543735
- Pharmacy Regulatory Specialist Certification January 2017 to Present Pharmacy Regulatory Specialist certifies a pharmacy technician to obtain the knowledge and understand the different laws and regulations for controlled substances in regards to the DEA and states.
- Registered Pharmacy Technician November 2014 to Present Registration for the state of Florida for pharmacy technician in order to work in a pharmacy setting.
- PTCB October 2007 to Present Pharmacy Technician national certification
- BLS Certification
- Compact State Nurse License
- RN License
- Pharmacy Technician License
- CPR Certification
- Driver's License
Languages
Spanish, English - Fluent
Timeline
Concurrent Review Nurse
Leon Medical Centers
10.2022 - Current
Registered Nurse (RN)
Unity rehabilitation
03.2022 - 03.2023
Prior Authorization Pharmacy Technician
Molina Healthcare Inc
06.2017 - 09.2022
Order Entry Technician
ProcareRx
10.2016 - 06.2017
Senior Training Associate(pharmacy)
OPTUM/UnitedHealth Group/Briova Specialty
12.2014 - 08.2016
Tech Translation Technician(Data Entry)
Catamaran Home Delivery
05.2012 - 12.2014
Order Entry Technician
Catamaran Home Delivery
05.2012 - 12.2014
Inventory Specialist
Catamaran Home Delivery
05.2012 - 12.2014
Task Force Technician
Catamaran Home Delivery
05.2012 - 12.2014
Failed Claims Technican
Catamaran Home Delivery
05.2012 - 12.2014
Data Entry Specialist
Walgreens Co.
05.2009 - 05.2012
Resolution Specialist
Walgreens Co.
05.2009 - 05.2012
Certified Pharmacy Technician
Walgreens
12.2005 - 04.2009
Recreational Leader
City Of Hialeah Parks AND RECREATION
04.2004 - 11.2005
High School Diploma - undefined
Barbara Goleman Senior High
Associate's degree - Pharmacy
Miami Dade College
Diploma - undefined
Miami Lakes Education Center
Associate's degree - Nursing
Miami Regional University
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