Distinguished Registered Nurse with a robust background at Presbyterian Hospital, adept in critical care and emergency response. Leveraging bilingual capabilities and exceptional organizational skills, I excel in fast-paced environments, ensuring high-quality patient care and efficient team coordination. Proven track record in improving patient outcomes and streamlining authorization processes, demonstrating a commitment to excellence and patient advocacy.
• Analyzed all prior authorization requests to determine the medical necessity of services and the appropriate level of care in accordance with national standards, contractual requirements, and a member's benefit coverage.
• Provided recommendations to the appropriate medical team to promote the quality and cost-effectiveness of medical care. Perform medical necessity and clinical reviews of authorization requests to determine the medical appropriateness of care in accordance with regulatory guidelines and criteria.
• Worked with healthcare providers and the authorization team to ensure a timely review of services and/or requests, to ensure members receive authorized care.
• Coordinated, as appropriate, with healthcare providers and interdepartmental teams to assess the medical necessity of care for the member.
• Escalated prior authorization requests to Medical Directors, as appropriate, to determine the appropriateness of care.
• Assisted with service authorization requests for a member’s transfer or discharge plans to ensure a timely discharge between levels of care and facilities.
• Collected, documented, and maintained all members' clinical information in health management systems to ensure compliance with regulatory guidelines.
• Assists with providing education to providers and/or interdepartmental teams on utilization processes to promote high-quality and cost-effective medical care to members.
• Provided feedback on opportunities to improve the authorization review process for members .
• Performed other duties as assigned.
• Complied with all policies and standards.
3D Mask Makers, 04/01/20, My best friend, also a nurse, organized a group of engineers, and medical staff in created 3D printed masks and face shields. Due to the shortage of PPE for healthcare workers, it had created an environment of fear and sadness, however many individuals have come together to make an impact on the situation the we all have been facing together.
Spanish, Fluent
RN, 01/01/23, NM
Authorized To Work: US