EYDEE MANZANO
Claim review nurse
Palmdale,CA
Summary
Analytical and strategic utilization review nurse with excellent problem-solving and time management skills. Organized, efficient and always willing to go extra mile to meet expectations.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Utilization / Claims Review Nurse
High Desert Medical Group
06.2015 - Current
- Assures the patient is in the appropriate status and level of care based on Medical Necessity process and submits for Secondary Physician review per High Desert Medical Group policy
- Ensures timely communication of clinical data to various payers to support admission, level of care, length of stay and authorization for post-acute services
- Completion of clinical reviews, Coordinates clinical care (medical necessity, appropriateness of care and resource utilization for admission, continued to stay, discharge and postacute care) supported by evidencebased practice, internal and external requirements
- Responsible for retrospective medical claim reviews of rendered inpatient and outpatient health care services to confirm medical necessity and appropriateness of billing for High Desert Medical Care members
- Collaborates with the Integrated Healthcare Services team and providers to ensure proper payment for appropriate, high quality, cost effective healthcare services according to State and Federal guidelines.
Clinical LVN
Antelope Valley Community Clinic
01.2012 - 06.2015
- Dispensary Nurse position is responsible for the safe and efficient dispensing of manufactured medication to clients, consistent with the clinic procedures
- Record all doses dispensed and account for all medications distribute during a dispensary shift
- Accurately record patient details in the electronic medical records system
- Organize and monitor the activities of the Dispensary Nurse as requested by the Lead Dispensary Technician or Dispensary MD
- Attend such meetings as directed by the Dispensary Manager(s) and report to the Medical Director as required
- Utilized strong assessment skills to determine necessary patient care
- Interviewed patients to obtain medical information and measure vital signs, weight and height
- Educated patient and family regarding disease process and individual care needs
- Administered medications and treatments to residents per doctor orders
- Evaluated patient care needs and prioritized treatment to maintain patient flow.
Education
Earned Credit Towards AA In A.S Nursing -
Antelope Valley Collage
Lancaster, CARelevant Coursework -
University of Antelope Valley
Lancaster, CASkills
Determine Medical Necessity
Preventive Healthcare
Specialized Healthcare Referrals
Office Support
Obtaining Authorizations
InterQual Criteria
Accurate Documentation
CPT Coding
Certification
Licensed Vocational Nurse
References
References available upon request
Timeline
Utilization / Claims Review Nurse
High Desert Medical Group
06.2015 - Current
Clinical LVN
Antelope Valley Community Clinic
01.2012 - 06.2015
Earned Credit Towards AA In A.S Nursing -
Antelope Valley Collage
Relevant Coursework -
University of Antelope Valley
Similar Profiles
CYNTHIA GONZALEZCYNTHIA GONZALEZ
Adminstrative Team /Client Services Member Representative at High Desert Medical GroupAdminstrative Team /Client Services Member Representative at High Desert Medical Group
Isabella SalazarIsabella Salazar
Claims Customer Service Representative at High Desert Medical GroupClaims Customer Service Representative at High Desert Medical Group
Kassandra OchoaKassandra Ochoa
Hierarchical Condition Category Coordinator at High Desert Medical GroupHierarchical Condition Category Coordinator at High Desert Medical Group