Estefany Merced
Utilization Management Supervisor
San Juan, PR
Summary
Competitive problem solver who thrives on raising standards and achieving success. Experienced optimizing productivity, efficiency and service quality across various environments. Smart critical thinker and problem-solver due to dynamic patient care planning and understanding of Medicare guidelines.
Overview
4
4
years of professional experience
Work History
Utilization Management Supervisor
Hospital Pavia Santurce
San Juan , PR
2022.04 - Current
- Direct Supervision of employees through day-to-day work and complex problems.
- Develop and implement effective record-keeping procedures.
- Case Discussion and appeals.
- Keep dated the billing process.
- Digitalization of reports with denials, analysis of reports and implementation of work projects.
- Promote teamwork, goals achievement and employees success with coaching and improvement strategies.
- Establish level-of-care determinations using InterQual criteria.
- Act as a resource to both the hospital and the physician.
Medical Advisor
CDAM Group LLC
Morovis , PR
2020.11 - Current
- Improve HCC coding accuracy and Risk Adjustment.
- Evaluation of electronic health records for medical appropriateness and make recommendations based on patient needs.
- Monitoring services specific to the individual safety needs and risks in conjunction with comorbidity issues.
- Overall utilization tracking.
- Use and monitoring of services (HEDIS).
- Prepared working papers, reports and supporting documentation for audit findings.
- Evaluated patient histories, complaints and current symptoms.
- Teamed with other physicians, specialists and health care providers to provide well-rounded care for complex cases.
- Provided consultation to staff and administration on patient treatment.
- infeccontrol practices.
Utilization Management Supervisor
Hospital Metropolitano Dr. Susoni
2019.05 - 2020.10
- Develop and implement strategies to improve quality and metrics.
- Provide leadership to help clinical and non clinical staff understanding quality measures and coach them on how to implement them based on their duties.
- Case Discussion and clinical appeals.
- Promote teamwork, goals achievement and employees success with coaching and improvement strategies.
Utilization Management Coordinator
Hospital Metropolitano Dr. Susoni
2018.12 - 2019.04
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed admission reviews based for medical necessity.
- Communicated with medical staff quality issues, provide feedback and recommendations to better cost effectiveness through good utilization of resources.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Fostered excellence by example by "setting pace" and being hands on mentor to clinical staff.
Education
Medicine Doctor -
Universidad Central del Este
San Pedro De Macorís, DR2018
Bachelor's degree - Human Biology
Universidad de Puerto Rico
Bayamón, PR2012
Skills
- Quality
- Strategic Planning
- Results Orientation
- Originality and Creativity
- Problem Anticipation and Resolution
- Critical Thinking
- Research and Analysis
- Confidence and Drive
- Medical Writing
- Symptom Assessment and Evaluation
- Risk Management Strategies
- Explaining Complex Diagnoses
- History Evaluations
- Medical Assessments
- Primary Care
- Project Implementation
- Medical Diagnosis
- Medical Issues Management
- Data Analysis
- Improving Wellbeing
- Interdisciplinary Care
- EMR Systems
- Compliance Issues
- Reviewing Patient Information
- Patient Data Management Systems
- Superior Levels of Care
- Interpreting Laboratory Results
- Complex Problem-Solving
- Creative Thinking
- Quality Improvement Plans
- Analyzing Test Results
- Optimal Resource Utilization
Languages
Spanish
Bilingual or Proficient (C2)
English
Bilingual or Proficient (C2)
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Quote
The person who says it cannot be done should not interrupt the person who is doing it.
Chinese proverb
Timeline
Utilization Management Supervisor
Hospital Pavia Santurce
2022.04 - Current
Medical Advisor
CDAM Group LLC
2020.11 - Current
Utilization Management Supervisor
Hospital Metropolitano Dr. Susoni
2019.05 - 2020.10
Utilization Management Coordinator
Hospital Metropolitano Dr. Susoni
2018.12 - 2019.04
Medicine Doctor -
Universidad Central del Este
Bachelor's degree - Human Biology
Universidad de Puerto Rico
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