Dulce Rivera
Miami Lakes,FL
Summary
Enthusiastic Registered Nurse with over ten years of experience, with excellent people skills and dedicated work ethic. Solid clinical, utilization review and case management experience with knowledge of FL Medicaid, Marketplace and Medicare laws and regulations, pursuing long-term position with room for growth and career advancement.
Overview
11
11
years of professional experience
Work History
Utilization review nurse
South Miami Hospital
12.2019 - Current
- Increases patient throughput to the most appropriate level of care while facilitating interdisciplinary care across the continuum while maintaining regularity compliance
- The role Integrates, coordinates care facilitation throughput while working in partnership with the healthcare team
- Is accountable for prioritizing, reviewing cases to determine the appropriateness of pre-admission, admission utilizing payer established criteria Assisting in identifying appropriate patient status and level of care
- Identify readmissions managing per policy
- Identify possible inappropriate hospitalizations and collaborate with the healthcare team to facilitate alternate Level of Care
- Assist in identifying physician and staff documentation opportunities to support Quality and Pay for Performance indicators.
Concurrent Review Nurse/Prior Authorization Nurse/Appeal nurse/Claims reviewer Commercial/Medicaid
Evolent Health Remote
01.2019 - 05.2022
- Conduct initial admissions review, concurrent review, retrospective chart review requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
- Review member’s appeal on timeline manner, investigate rationalization for denial, follow Health plan policies, booklet benefits, Interqual and NCQA standards
- Review claims denied for medical necessity /benefit level exception, re-process claims or upheld based on medical necessity, clinical policy, benefit booklet and or Interqual
Concurrent Review Nurse
Aetna Health care WAH
09.2018 - 12.2018
- Conduct initial admissions review, concurrent review, retrospective chart review requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations.
Concurrent Review Nurse /Prior Authorization
Prestige Health Choice-Remote
07.2015 - 09.2018
- Conduct initial admissions review, concurrent review, retrospective chart review requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
- Review referral requests (routine, urgent & stat) for various office visits, outpatient and inpatient procedures using Medicaid, Company guidelines and IQ to determine medical necessity
- Coordinate reviews, referrals & denials with medical director, medical groups, health plans Create denial letters based on the MD's review and guidelines.
Precertification Nurse
Simply Healthcare-Remote
11.2013 - 06.2015
- Review referral requests (routine, urgent & stat) for various office visits, outpatient and inpatient procedures using Medicare/Medicaid guidelines, IQ along with company guidelines to determine medical necessity Coordinate reviews, referrals & denials with medical director, medical groups, health plans
- Create denial letters based on the MD's review and guidelines
Floor Nurse Per Diem
Palmetto Sub Acute
08.2013 - 11.2013
- Knowledge of nursing practice, medical methods and techniques Monitored vital changes in patient conditions including vital signs, glucose readings Administered approved medications under the in charge, Peg feedings/wound-dressing change.
Case Management
My Home Doctor
02.2013 - 09.2013
- Manage patient health status post Hospital/Rehab discharge
- Scheduling patients visit, process doctor’s orders, triage patient’s phone calls, order medications to pharmacy
- Place follow up calls to see how patient is doing after initial visit.
Case Management
Preferred Care Partners
11.2012 - 01.2013
- Conducts thorough and objective assessment of the client's current status, including a situational analysis and functional assessment covering various elements
- Facilitates coordination of comprehensive, individualized plan of care, in collaboration with patient, family and interdisciplinary team.
Education
A.S. in Nursing School -
Saber College
08.2014
Licensed Practical Nurse -
Medvance Institute
06.2012
M.A. and Coder Specialist Diploma -
Technical Career Institute
01.2001
High School Diploma -
Miami Senior High
06.1998
Skills
- Patient and family advocacy
- Strong clinical judgment
- Problem resolution capability
- Adept at prioritizing/managing deadlines
- Strong leadership and communication skills
- Fluent in English/Spanish
- Dedicated and Fast learner
- Team Player, flexibility
- High level of autonomy
- Discharge Planning Coordination
- Utilization Review
- Case Management
Programs
Jira-QTNX-IOS health system-NextGEN-Jiva 5.6-IQ-Identifi-MCG-Jira-Aldera-IQ-MCG
References
Available upon request.
Timeline
Utilization review nurse
South Miami Hospital
12.2019 - Current
Concurrent Review Nurse/Prior Authorization Nurse/Appeal nurse/Claims reviewer Commercial/Medicaid
Evolent Health Remote
01.2019 - 05.2022
Concurrent Review Nurse
Aetna Health care WAH
09.2018 - 12.2018
Concurrent Review Nurse /Prior Authorization
Prestige Health Choice-Remote
07.2015 - 09.2018
Precertification Nurse
Simply Healthcare-Remote
11.2013 - 06.2015
Floor Nurse Per Diem
Palmetto Sub Acute
08.2013 - 11.2013
Case Management
My Home Doctor
02.2013 - 09.2013
Case Management
Preferred Care Partners
11.2012 - 01.2013
A.S. in Nursing School -
Saber College
Licensed Practical Nurse -
Medvance Institute
M.A. and Coder Specialist Diploma -
Technical Career Institute
High School Diploma -
Miami Senior High