Cortez Washington
Fontana,CA
Overview
20
20
years of professional experience
Work History
Prior Authorization Review Nurse
San Francisco Health Plan (SFHP)
11.2022 - 08.2025
- MCG criteria review for use in outpatient services, CPT/HCPC Codes, case escalations, MD consults, NOA Letter creation, use of HLA grade 6, Denial letter creation, submission to MRI of A (if recommended by MD), CCS referral, DME, MCG clinical criteria review, and medical provider manual criteria.
- Specialties: When to write an MD consultant for OON/OOP requests.
- Gender Affirmation trained criteria, WPATH, Adult, and Adolescent, PDR, fraud, waste, and abuse, CMS, SDN, Dual LOB, and LOB.
- Eligibility checks.
UM/UR Nurse
LA Care Health Plan
01.2019 - 01.2022
- Duties: ED, HLOC, transfers, escalations to UM MD
RN ED Case Manager
Kaiser Permanente
08.2017 - Current
- ED Care management: Utilizing InterQual/CERME, EPIC, and Teams.
- Collaborate with all levels of the healthcare team, including physicians, interdisciplinary teams, payors, and administration, to address care management process improvement issues.
- Review assigned admissions for acute care needs, using established and accepted criteria.
- Monitor all admissions, initial assessments, and discharge planning through the emergency department.
- Evaluate all Medicare, Medi-Cal, Medi-Cal HMO, PPO/HMOs, Industrial (Workmen's Comp), and all major payors for SI and IS with InterQual software.
RN ED Case Manager
Riverside University Health System (RUHS)
02.2017 - 12.2018
- ED Care management: Utilizing InterQual/CERME, EPIC, and Teams.
- Collaborate with all levels of the healthcare team, including physicians, interdisciplinary teams, payors, and administration, to address care management process improvement issues.
- Review assigned admissions for acute care needs, using established and accepted criteria.
- Monitor all admissions, initial assessments, and discharge planning through the emergency department.
- Evaluate all Medicare, Medi-Cal, Medi-Cal HMO, PPO/HMOs, Industrial (Workmen's Comp), and all major payors for SI and IS with InterQual software.
ED Case Manager: LVN to RN
Providence Little Company of Mary (LCM)
12.2005 - 07.2015
- Provide direct service intervention to individual patients and families, including Initial assessments and care coordination, and discharge planning.
- ED Care management: using InterQual/CERME (book and computer version), EPIC/Health Connect, CAMIS, Logi care, and Meditech systems.
- Collaborate with all levels of the healthcare team, including physicians, interdisciplinary teams, payors, and administration, to address care management process improvement issues.
- Review assigned admissions for acute care needs, using established and accepted criteria.
- Monitor all admissions, initial assessments, and discharge planning through the emergency department.
- Evaluate all Medicare, Medi-Cal, Medi-Cal HMO, PPO/HMOs, Industrial (Workmen's Comp), and all major payors for SI and IS with InterQual software.
- Monitor the activity of observation status patients, as well as Inpatient status to ensure patients remain within the DRG, and admission to in-house status meets acute care criteria per Medicare.
- Educate hospital staff and physicians on current information, including inpatient vs. observation criteria, DRGs, and appropriate clinical documentation.
- Maintain complete documentation in the medical record, Meditech and on Care Management worksheets of interventions and outcomes of discharge planning process.
- Write up all clinical medical reviews on e-Medi-Cal Tars (18-1) daily, including retroactive Tars on newly approved Medical-Cal patients.
- Clinical reviews are also provided to case managers for Workmen's Comp and PPO/HMO payors.
Timeline
Prior Authorization Review Nurse
San Francisco Health Plan (SFHP)
11.2022 - 08.2025
UM/UR Nurse
LA Care Health Plan
01.2019 - 01.2022
RN ED Case Manager
Kaiser Permanente
08.2017 - Current
RN ED Case Manager
Riverside University Health System (RUHS)
02.2017 - 12.2018
ED Case Manager: LVN to RN
Providence Little Company of Mary (LCM)
12.2005 - 07.2015