Summary
Overview
Work History
Education
Skills
Affiliations
Languages
Timeline
Hi, I’m

Dulce Navarro BSN, RN

Murrieta,CA

Summary

Patient-oriented Nurse with 16 years of diverse experience in direct patient care, staff supervision, and department operations. Skilled at multitasking and prioritizing patient needs and daily assignments. Offering expertise with Managed Care.

Overview

9
years of professional experience

Work History

TrueCare

Registered Nurse
07.2022 - Current

Job overview

  • Assess and triage patients for medical and behavioral health conditions in-person and over phone.
  • Provide direct patient care within scope of practice.
  • Administer medications and vaccines, and interpret TB skin tests.
  • Enter patient data in electronic health record (EHR) system and order/interpret laboratory tests.
  • Oversee immunizations and coordinate nursing schedules for coverage.
  • Monitor and evaluate clinical skills competencies of team of ten medical assistants.
  • Develop and implement individualized plan of care for patients.
  • Maintained medication and lab supply expiration dates and prepare for audits.
  • Serve as point of contact for staff questions, patient conflicts, and care advocacy.
  • Ensure adherence to state and federal laws for efficient department operations, reporting, and quality assurance.
  • Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
  • Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.

AHCCCS- State Of Arizona MEDICAID

Utilization Review Nurse
11.2021 - 07.2022

Job overview

  • Perform utilization reviews based on evidence-based guidelines and criteria (CPT codes, dx codes).
  • Provide provider education and training in prior authorization.
  • Conduct clinical reviews of claims for medical necessity, coding accuracy, and policy compliance.
  • Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
  • Coordinate and advocate for care needs of medical and behavioral health members.
  • Review and authorize behavioral healthcare services, ensuring adherence to regulations.
  • Coordinate services and authorizations for members' transition of care.
  • Develop and review member-centered documentation, ensuring compliance with standards.
  • Identify and intervene in potential quality of care issues and elevate to Quality Care team as appropriate.
  • Collaborate with Case Management for acute inpatient needs affecting discharge.
  • Participate in care coordination and discharge planning meetings.
  • Maintained quality and productivity metrics, meeting goals.
  • Provide support and training to new nurses and staff.
  • Ensure HIPAA compliance in telework environment.

AHCCCS- State Of Arizona MEDICAID

Nurse Case Manager
09.2019 - 11.2021

Job overview

  • Coordinated care and follow-ups for medical and behavioral health members.
  • Advocated for members' care needs and addressed gaps in care.
  • Reviewed clinical documentation for claims and prior authorizations.
  • Coordinated services and authorizations for members' transition of care.
  • Participated in clinical staffing/meetings for care coordination and discharge planning.
  • Cross-trained to assist with claims medical services and utilization reviews.
  • Improved weekly turnaround time goals to keep under 3%.
  • Analyzed reports and logs to improve metrics.
  • Assisted in developing policies and procedures for covered services.
  • Trained new nurses and staff members.
  • Escalated complex cases to management or quality care teams.
  • Assisted with emergency continuity of operations and member transfers.
  • Participated in LEAN activities to support team and division goals.

Dignity Health St Joseph's Medical Center

Registered Nurse
07.2019 - 09.2019

Job overview

  • Implemented individualized care plans based on physicians' medical regimens.
  • Provided attentive care to 1-2 patients in 32-bed Neuro ICU unit.
  • Demonstrated effective communication skills with staff, patients, providers, and families.
  • Maintained personal and health data confidentiality in compliance with HIPAA laws.
  • Advocated for patient health, safety, and rights.
  • Conducted ongoing monitoring and evaluations, promptly reporting relevant information to clinical supervisors.
  • Educated patients and caregivers on treatment plans and medication side effects.
  • Maintained accurate documentation of treatments, medications, IVs, discharge instructions, and follow-up care.
  • Collaborated in inpatient discharge planning.

AHCCCS- State Of Arizona MEDICAID

Prior Authorization Technician
05.2014 - 09.2019

Job overview

  • Managed over 50 provider calls daily, verifying eligibility and prior authorization status.
  • Maintained productivity and quality in claims processing.
  • Cross-trained in prior authorization and claims adjudication for unit support.
  • Generated monthly reports using advanced Excel functions.
  • Researched and notified providers of denied claims or prior authorizations.
  • Assisted in training new employees and educated providers on online request system.
  • Ensured compliance with authorization requirements and verified eligibility.
  • Triaged unscheduled and emergency authorizations promptly.
  • Prepared and distributed denial letters with detailed reasons and appeal information.

Education

Herzing University
Milwaukee, WI

Master of Science from PMHNP
12.2024

Arizona State University
Tempe, AZ

Bachelor of Science from Nursing
12.2019

Phoenix Community College
Phoenix, AZ

Associate of Science from Nursing
05.2019

Skills

  • Clinical knowledge and expertise
  • Utilization review and medical necessity assessment
  • Critical thinking and analytical skills
  • Attention to detail and accuracy
  • Effective communication and interpersonal skills
  • Decision-making and problem-solving abilities
  • Time management and organizational skills
  • Collaboration and teamwork
  • Compliance with regulatory and accreditation standards
  • Proficiency in healthcare documentation and electronic health records (EHR)
  • Adaptable and able to work in fast-paced environment
  • Continuous learning and staying updated with industry trends and guidelines

Affiliations

National Association of Hispanic Nurses (NAHN)
National Hispanic Medical Association (NHMA)

AHCCCS Leadership Academy

Languages

Spanish
Native or Bilingual

Timeline

Registered Nurse

TrueCare
07.2022 - Current

Utilization Review Nurse

AHCCCS- State Of Arizona MEDICAID
11.2021 - 07.2022

Nurse Case Manager

AHCCCS- State Of Arizona MEDICAID
09.2019 - 11.2021

Registered Nurse

Dignity Health St Joseph's Medical Center
07.2019 - 09.2019

Prior Authorization Technician

AHCCCS- State Of Arizona MEDICAID
05.2014 - 09.2019

Herzing University

Master of Science from PMHNP

Arizona State University

Bachelor of Science from Nursing

Phoenix Community College

Associate of Science from Nursing
Dulce Navarro BSN, RN