Deborah Ramirez
Summary
Effective and compassionate former bedside nurse with 18 years Utilization Review and Discharge Planning experience. Dedicated to delivery of appropriate, efficient and safe patient care.
Overview
25
25
years of professional experience
Work History
Utilization Review and Appeals/Grievances Coordinator
Clearlink Partners LLC
03.2022 - 08.2023
- Responsibilities include health plan member grievance investigation and resolution. Grievances are referred to the Physician Advisor for possible provider education and member focused outcomes.
- Former assignment included Utilization Review for members enrolled in Caremore, including their Medicare, Medicaid and commercial platforms. Claims and appeals could exceed six figures up to and over 1 million dollars.
Utilization Review Nurse
Amerigroup Community Care
06.2009 - 11.2020
- Reviewed inpatient hospitalizations on-site and via telephone for Maryland Amerigroup members enrolled in a managed Medicaid program
- Referred cases to secondary review for failure to meet Milliman and/or Interqual criteria
- Coordinated a plan of care with physicians, nurses and discharge planners
- Kept detailed documentation on all utilization reviews by using Facets software
- Maintained strict patient data procedures to comply with HIPAA laws and prevent information breaches
Utilization Review Nurse
United Health Care
05.2007 - 04.2009
- Performed admission reviews based on medical necessity using Milliman and Interqual guidelines both on-site and via EMR
- Communicated with healthcare team members to plan, implement and enhance treatment strategies
- Coordinated individualized discharge plans to manage safe transition back into community and home environments
Telephone Triage Nurse
United Health Care
07.2006 - 04.2007
- Provided telephone triage and advice to United Health Care members
- Reviewed symptoms, medications and treatment options with callers and facilitated communication with primary care physicians
- Assisted callers with locating primary care physicians and/or specialty health care providers
- Coordinated with healthcare team to establish, enact and evaluate patient care plans
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions
Bedside Registered Nurse
Various Local Washington DC Area Hospitals
06.1998 - 06.2006
- Managed elements of patient care, from admission to discharge or transfer to other units, using nursing expertise to conduct assessments, administer medications, initiate nursing and emergency interventions, contribute to care plan development and educate patients
- Delivered medications via oral, IV and intramuscular injections, monitoring responses to catch and address new concerns
- Assessed physical, psychological, physiologic and cognitive status of patients
- Conferred with physicians to discuss diagnoses and devise well-coordinated treatment approaches
- Observed and reported patient condition, progress and medication side effects to accurately document updates
Education
Bachelor of Science - Nursing Education
Western Governors University
Salt Lake City, UT05.2018
Associate of Science - Nursing
Howard Community College
Columbia, MD1998
Skills
- Microsoft Windows, Office, Excel, RightFax, Maccess, Facets
- EMR / EHR - Midas, Cerner, DataNet, Availity, DRE, Essette
- Interpersonal and written communication
- Discharge planning coordination
Accomplishments
- Certifications: Certified Professional in Healthcare Management
Certification
Registered Nurse with a Multistate Compact and States of California and Nevada licenses.
Timeline
Utilization Review and Appeals/Grievances Coordinator
Clearlink Partners LLC
03.2022 - 08.2023
Utilization Review Nurse
Amerigroup Community Care
06.2009 - 11.2020
Utilization Review Nurse
United Health Care
05.2007 - 04.2009
Telephone Triage Nurse
United Health Care
07.2006 - 04.2007
Bedside Registered Nurse
Various Local Washington DC Area Hospitals
06.1998 - 06.2006
Bachelor of Science - Nursing Education
Western Governors University
Associate of Science - Nursing
Howard Community College
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