GERALDINE RIVERA CASTILLO
Grand Island,Fl
Summary
Patient-oriented Nurse with 24 years of diverse experience in direct patient care, staff supervision and department operations. Skilled at multitasking and prioritizing patient needs and daily assignments. Offering expertise with diverse experience of specialty. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals.
Overview
16
16
years of professional experience
Work History
CONCURRENT REVIEW NURSE I
Centene (Sunshine Health Insurance)
12.2017 - Current
- Conduct concurrent reviews of patient medical records to assess the necessity and appropriateness of hospital admissions and continued stays
- Evaluate the severity of illness, intensity of service, and medical necessity for ongoing care
- Collaborate with healthcare providers, including physicians, specialists, and case managers, to ensure that care is provided in the most efficient and effective manner
- Advocate for the appropriate level of care and services for patients
- Maintain accurate and detailed records of concurrent review activities, including findings, recommendations, and interventions
- Generate reports and communicate with relevant stakeholders to provide updates on review outcomes
- Apply evidence-based clinical criteria, guidelines, and established protocols to make determinations regarding the necessity and appropriateness of care
- Effectively communicate with healthcare teams, insurance companies, and other stakeholders to ensure timely and appropriate care transitions
- Facilitate discussions regarding discharge planning and post-hospital care
- Participate in quality improvement initiatives to enhance patient outcomes, reduce readmissions, and improve overall care delivery
- Ensure compliance with all applicable healthcare laws, regulations, and policies, including those related to concurrent review processes
- Provide education to patients and families on the review process, available resources, and strategies for self-care management.
- Enhanced interdisciplinary collaboration by participating in daily rounds, discussing patient cases, and providing clinical input.
- Served as a liaison between healthcare providers, insurers, patients, and families to facilitate communication and resolve issues related to care coordination or coverage determinations.
RN REHAB
PAM Rehab Center
10.2023 - 12.2023
- Conduct thorough assessments of patients' physical and psychological conditions, focusing on rehabilitation needs and goals
- Develop individualized care plans in collaboration with the interdisciplinary team to optimize patient recovery
- Administer and monitor rehabilitative treatments, therapies, and medications to support patients in achieving their functional goals
- Provide education and guidance to patients and families on self-care techniques and adaptive strategies
- Educate patients and their families on the rehabilitation process, setting realistic expectations, and providing resources for continued progress
- Work closely with physical therapists, occupational therapists, speech-language pathologists, and other healthcare professionals to ensure coordinated and comprehensive care
- Regularly evaluate patient progress, adjust care plans as needed, and maintain accurate documentation of assessments, interventions, and outcomes
- Monitor and manage pain levels, implementing appropriate interventions and collaborating with the healthcare team to optimize pain relief
- Collaborate with the care team to plan and execute safe and effective transitions of care, including arranging for outpatient services and follow-up appointments.
RN SUPERVISOR / CHARGE NURSE
Fresenius Kidney Care
12.2016 - 11.2017
- Provide leadership and guidance to a team of Dialysis Nurses, ensuring efficient workflow, adherence to protocols, and delivery of high-quality patient care
- Conduct comprehensive assessments of patients before and during dialysis treatment, monitoring vital signs and making adjustments as necessary
- Develop and oversee individualized dialysis treatment plans, collaborating with the healthcare team to ensure safe and effective care
- Monitor and maintain compliance with regulatory standards, company policies, and industry best practices, implementing corrective actions as needed
- Facilitate ongoing training and professional development for Dialysis Nurses, keeping them updated on the latest techniques, equipment, and protocols
- Educate patients and their families on kidney health, dialysis procedures, and self-care techniques, empowering them to manage their condition effectively
- Maintain accurate and detailed records of dialysis treatments, assessments, and patient progress, ensuring compliance with documentation standards
- Oversee the maintenance and proper use of dialysis equipment, ensuring its availability and functionality for all treatments.
- Served as an approachable leader who consistently addressed concerns raised by both nursing staff and families regarding patient care issues or operational challenges within the unit effectively resolving them promptly whenever possible.
- Managed critical situations calmly and efficiently, providing guidance to the nursing team during emergencies.
- Improved patient satisfaction scores by fostering a collaborative and supportive team environment.
- Cultivated an atmosphere of teamwork and open communication among staff members, resulting in a more cohesive work environment and greater job satisfaction for the nursing team.
- Led quality improvement projects aimed at enhancing overall patient outcomes within the department through close collaboration with multidisciplinary teams.
- Increased staff retention rates through effective mentoring, coaching, and professional development opportunities.
- Reduced medication errors by providing thorough training and supervision to nursing staff.
- Ordered all pharmacy supplies and kept check on inventory levels.
- Conducted routine facility inspections, identifying areas needing improvement and eliminating hazards posed to staff and residents for continued compliance with associated regulations.
- Scheduled surgeries, managed pre-certifications and verified insurance coverage.
- Removed trash and straightened counters to keep pharmacy area clean and neat.
- Trained new nurses in proper techniques, care standards, operational procedures, and safety protocols.
- Managed staffing schedules, ensuring adequate coverage while minimizing overtime expenses.
- Maintained accurate documentation of patient information, enabling informed decision-making among the healthcare team members.
RN Supervisor
Heartland Hospice
05.2016 - 12.2016
- Managed critical situations calmly and efficiently, providing guidance to the nursing team during emergencies.
- Served as an approachable leader who consistently addressed concerns raised by both nursing staff and families regarding patient care issues or operational challenges within the unit effectively resolving them promptly whenever possible.
- Improved patient satisfaction scores by fostering a collaborative and supportive team environment.
- Consistently acted as a strong advocate for patients and their families, ensuring that their needs were met while navigating complex healthcare systems.
- Promoted a culture of continuous improvement within the nursing department by regularly soliciting feedback from staff members and incorporating suggestions into practice when appropriate.
- Decreased hospital readmission rates through diligent monitoring of high-risk patients and proactive interventions as needed.
- Increased staff retention rates through effective mentoring, coaching, and professional development opportunities.
- Developed and distributed nursing assignments for unit employees that outlined individual and group tasks.
- Evaluated and monitored care and services throughout shift to improve quality levels.
- Inventoried medications, supplies and equipment and distributed stock to patients.
Utilization Management Supervisor
Molina Healthcare
03.2015 - 05.2016
- Conducted regular evaluations of staff performance, providing constructive feedback and implementing appropriate interventions when necessary to improve overall team effectiveness.
- Managed high-profile cases effectively, ensuring timely resolution of complex utilization issues for patients, providers, and payers.
- Reduced hospital readmissions by identifying trends in patient care and recommending targeted interventions.
- Devised innovative solutions to address gaps in care or inefficiencies within the utilization management process.
- Increased compliance with regulatory requirements by monitoring adherence to guidelines and protocols within the utilization management department.
- Mentored junior staff members on best practices within the field of utilization management, fostering a culture of continuous learning and professional growth among team members.
- Facilitated accurate documentation processes while ensuring compliance with relevant industry standards and organizational policies.
- Conducted comprehensive audits of departmental operations to identify areas for improvement or potential risks related to non-compliance with regulations.
- Collaborated with data analysts to review performance metrics, identify trends, and inform strategic planning initiatives related to utilization management operations.
- Built strong relationships with external stakeholders such as hospitals, clinics, provider networks, and insurance carriers to facilitate seamless coordination in service delivery.
- Played a key role in the development and implementation of departmental policies and procedures aimed at maintaining high-quality care standards while adhering to regulatory guidelines within the scope of utilization management activities.
- Supported leadership initiatives aimed at improving organizational performance related to health plan accreditation standards or contractual obligations with insurers/providers networks'' agreements.
- Hired, managed, developed and trained staff, established and monitored goals, conducted performance reviews and administered salaries for staff.
- Coordinated individual duties after careful evaluation of each employee's skill level and knowledge.
- Completed bi-weekly payroll for [Number] employees.
UTILIZATION MANAGEMENT SUPERVISOR
MMM Holdings, San Juan - PR
03.2014 - 03.2015
- Provide leadership and guidance to a team of Utilization Management Nurses, ensuring efficient workflow, adherence to policies, and timely completion of tasks
- Oversee the utilization review process, ensuring compliance with established guidelines, policies, and regulatory requirements
- Conduct complex utilization reviews, evaluating medical records, treatment plans, and patient progress to determine the appropriateness and medical necessity of care
- Collaborate with insurance providers to obtain necessary authorizations for inpatient stays and procedures, ensuring accurate and comprehensive clinical documentation
- Monitor and assess the quality and accuracy of utilization management activities, providing feedback and implementing process improvements as needed
- Facilitate training programs and ongoing education for Utilization Management Nurses, keeping them informed of industry updates and best practices
- Generate and analyze utilization management reports, providing insights and recommendations to support decision-making and process enhancement
- Foster effective communication and collaboration with healthcare teams, insurance companies, and other stakeholders to optimize patient care and resource utilization.
NURSING PROFESSOR
National University College, Bayamon Campus- PR
11.2008 - 11.2014
- Develop, revise, and implement nursing curriculum that aligns with industry standards and regulatory requirements
- Deliver engaging lectures, seminars, and practical sessions on various nursing topics, ensuring an inclusive learning environment
- Oversee clinical experiences for nursing students, providing guidance, supervision, and constructive feedback to ensure safe and effective patient care
- Design and administer assessments, exams, and evaluations to measure student performance and ensure program effectiveness
- Stay current with advancements in nursing education, attending conferences, workshops, and pursuing continuing education opportunities.
- Monitored progress of each student and provided formal evaluation upon completion of clinical placements.
- Developed and created clinical assignments to assess student skills.
- Coached underperforming students to help meet clinical objectives
- Prepared and administered weekly examinations to test student skills.
- Coordinated with clinicians to develop and coordinate student assignments.
- Developed strong relationships with clinical partners, ensuring quality placements for all nursing students during their practicum experiences.
- Served as an academic advisor to nursing students, helping them navigate program requirements and achieve their career goals.
- Established a positive classroom atmosphere by promoting open communication, empathy, and mutual respect among nursing students.
- Compiled, administered and graded examinations to evaluate and record student comprehension levels.
Concurrent Review Nurse
MMM Holdings, San Juan - PR
11.2012 - 03.2014
- Conduct concurrent reviews of inpatient cases to assess medical necessity, appropriateness of care, and compliance with established guidelines and criteria
- Evaluate patients' medical records, including diagnoses, treatment plans, and progress notes, to determine the most appropriate level of care
- Collaborate with healthcare teams, including physicians, specialists, and other care providers, to discuss patient status and develop effective care plans
- Communicate with insurance companies and payers to obtain authorizations for continued inpatient stays and procedures, providing necessary clinical documentation
- Maintain accurate and detailed records of concurrent reviews, documenting clinical findings, decisions, and any recommended changes to the treatment plan
- Ensure compliance with all relevant healthcare laws, regulations, and policies, including those related to utilization review and insurance authorizations
- Advocate for patients to ensure they receive appropriate and timely care, and facilitate transitions of care as needed.
CASE MANAGEMENT
HIMA Saint Paul Hospital, Bayamon - PR
03.2010 - 08.2012
- Conduct comprehensive assessments of patients' medical, social, and psychosocial needs
- Develop individualized care plans in collaboration with the healthcare team to ensure appropriate level of care and support
- Coordinate with multidisciplinary teams, including physicians, therapists, and social workers, to facilitate seamless transitions of care
- Advocate for patients to ensure they receive necessary resources, services, and interventions
- Review patient charts and records to evaluate the necessity and appropriateness of hospital admissions, continued stays, and discharges
- Work closely with insurance companies and payers to ensure compliance with coverage and authorization requirements
- Plan and coordinate safe and timely discharges, including arranging for home healthcare, durable medical equipment, and follow-up appointments
- Provide patient education on post-discharge instructions and self-care management
- Maintain accurate and up-to-date documentation of patient assessments, care plans, and interventions in electronic health records (EHR) systems
- Ensure compliance with all applicable healthcare laws, regulations, and policies, including HIPAA and CMS guidelines.
- Promoted family reunification through effective case management and advocacy efforts.
Education
Bachelor of Science - Nursing
PONTIFICAL CATHOLIC UNIVERSITY OF PR
Ponce, Puerto Rico12.1999
Skills
- Clinical Expertise: Extensive experience in various clinical settings, with proficiency in assessing, planning, implementing, and evaluating patient care
- Critical Thinking: Ability to make sound clinical judgments and decisions, especially in high-pressure situations
- Patient Advocacy: Strong advocate for patients' rights and well-being, ensuring they receive the highest quality of care
- Team Collaboration: Effective collaboration with multidisciplinary healthcare teams to provide comprehensive patient-centered care
- Care Coordination: Expertise in coordinating care plans, transitions, and discharge processes to ensure seamless patient experiences
- Patient Education: Skillful in providing clear and understandable instructions to patients and families regarding their care, medications, and self-management
- EMR Proficiency: Proficient in Electronic Medical Records (EMR) systems, ensuring accurate and up-to-date documentation of patient information
- IV Therapy and Medication Administration: Expertise in administering medications, including IV medications, and monitoring for potential adverse reactions
- Wound Care Management: Proficient in wound assessment, dressing changes, and implementing appropriate interventions for wound healing
- Patient Records Management: Organized and thorough management of patient records, ensuring confidentiality and compliance with legal regulations
- Continuing Education: Commitment to ongoing professional development, including attending workshops, seminars, and pursuing advanced certifications
- Medicare knowledge
- Quality Improvement
- Medicaid knowledge
- Healthcare regulations
- Clinical assessment
- Clinical judgment
- HIPAA Compliance
- Nursing Documentation
- Discharge Planning
- Managed Care
- Utilization review
- Interdisciplinary Collaboration
- HIPAA knowledge
- Medical record review
- Patient Safety
- Care Coordination
- Continuing education
- Teamwork and Collaboration
- Problem-Solving
- Medication and IV administration
- Time Management
- Attention to Detail
- Direct Patient Care
- Strong Clinical Judgment
- Critical Thinking
- Excellent Communication
- Decision-Making
- Blood Draw and Sample Collection
- Microsoft Office
- Medication Administration
- Case Management
Languages
Spanish
Native or Bilingual
Timeline
RN REHAB
PAM Rehab Center
10.2023 - 12.2023
CONCURRENT REVIEW NURSE I
Centene (Sunshine Health Insurance)
12.2017 - Current
RN SUPERVISOR / CHARGE NURSE
Fresenius Kidney Care
12.2016 - 11.2017
RN Supervisor
Heartland Hospice
05.2016 - 12.2016
Utilization Management Supervisor
Molina Healthcare
03.2015 - 05.2016
UTILIZATION MANAGEMENT SUPERVISOR
MMM Holdings, San Juan - PR
03.2014 - 03.2015
Concurrent Review Nurse
MMM Holdings, San Juan - PR
11.2012 - 03.2014
CASE MANAGEMENT
HIMA Saint Paul Hospital, Bayamon - PR
03.2010 - 08.2012
NURSING PROFESSOR
National University College, Bayamon Campus- PR
11.2008 - 11.2014
Bachelor of Science - Nursing
PONTIFICAL CATHOLIC UNIVERSITY OF PR
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