Elizabet Matos Hidalgo
Miami,United States
Summary
Registered Nurse and experienced Care Review Clinician with extensive background in utilization review, case management, and inpatient authorization determinations across Medicaid, Marketplace, and Medicare lines of business. Skilled in analyzing clinical documentation, evaluating medical necessity, and ensuring compliance with healthcare regulations and evidence-based guidelines. Recognized for strong clinical judgment, effective interdisciplinary collaboration, and the ability to thrive in fast-paced environments requiring accurate decisionmaking and timely outcomes.
Overview
8
8
years of professional experience
Work History
Utilization Review Nurse
Molina Healthcare
Miami, FL
11.2022 - Current
- Analyzed patient records and clinical documentation to determine medical necessity based on MCG guidelines and medical policies.
- Conducted comprehensive reviews of patients cases, assessing the appropriateness of care through critical analysis and data evaluation.
- Evaluated the medical necessity of healthcare services to ensure compliance with best practices and cost effective care.
- Developed and implemented personalized care plans to enhance patient outcomes.
- Identified opportunities for care delivery improvements and increased cost efficiency.
- Collaborated with physicians , healthcare professionals and interdisciplinary teams to optimize patient care.
- Provided expert recommendations for treatment plans and next steps in care management .
- Documented patient care plans, utilization review activities and clinical decisions.
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
Case Manager RN
West Gables Rehabilitation Hospital
Miami, FL
03.2022 - 11.2022
- Conducted comprehensive patient assessments at the time of admission.
- Evaluated patients to anticipate optimal care plans including transitions to SNF, ALF, LTAC. Home with HHC or Hospice.
- Applied compassion and critical thinking to assess patients needs from both clinical and social determinant perspectives.
- Educated patients and families on medical conditions, treatment options and transition of care processes.
- Coordinated the integration of social services and case management functions.
- Promoted efficient utilization of clinical resources, ensuring appropriate and cost effective care.
- Maintained ongoing communication with insurance providers and onsite representatives to facilitate approvals and reimbursements.
Registered Nurse
West Gables Rehabilitation Hospital
Miami, FL
10.2021 - 03.2022
- Provided comprehensive patient care , including assistance, education and support .
- Utilized critical thinking and advanced nursing skills.
- Conducted patient assessments, developed care plans, and facilitated discharge instructions to ensure continuity of care.
- Maintained accurate electronic documentation and nursing reports.
- Performed IV placements , medication administration , and vital monitoring with precision and adherence to safety protocols.
- Communicated effectively with physicians, interdisciplinary teams, and healthcare personnel to optimize patient outcomes.
Referral and Care Coordinator
Community Medical Group
Miami, FL
05.2017 - 09.2021
- Collaborated with healthcare providers, insurance companies, and patients to ensure appropriate scheduling, authorization, and follow-up of referrals.
- Communicated with patients regarding their healthcare needs and assist them with navigating the referral process.
- Monitored and tracked the status of patient referrals and appointments.
- Acted as a liaison between patients, healthcare providers, and insurance companies to facilitate clear communication and resolve any issues related to coverage or care.
- Educated patients about their care options and insurance benefits, promoting awareness and ensuring a smooth care coordination process.
Education
Bachelor of Science - Nursing
NUC University
Bayamon, PR01.2024
Associate of Science - Nursing
Universal Career School
Miami, FL01-2021
Bachelor of Science - Industrial Engineering
University of Cienfuegos
Cienfuegos, Cuba09-2012
Skills
- Utilization Review and Case Management
- Medical Record Review and Documentation
- Knowledge of Insurance Policies and Medical Guidelines
- Patient Advocacy and Care Coordination
- Strong Communication and Collaboration Skills
- Problem-Solving and Critical Thinking
- Detail-Oriented and Highly Organized
- Advanced knowledge of personal computers and software (MCG guidelines,QNXT, UMK2, Epic, MDFlow, Excel, Word, PowerPoint, OneNote)
- Bilingual English and Spanish (Proficient in written and spoken)
Timeline
Utilization Review Nurse
Molina Healthcare
11.2022 - Current
Case Manager RN
West Gables Rehabilitation Hospital
03.2022 - 11.2022
Registered Nurse
West Gables Rehabilitation Hospital
10.2021 - 03.2022
Referral and Care Coordinator
Community Medical Group
05.2017 - 09.2021
Bachelor of Science - Nursing
NUC University
Associate of Science - Nursing
Universal Career School
Bachelor of Science - Industrial Engineering
University of Cienfuegos