INGRID TEJADA
Los Angeles,California
Summary
Dependable Utilization Review Nurse promoting over 10 years of expertise in healthcare industry. Knowledgeable in admissions and stay reviews with a talent in reporting, records oversight and performance improvement. Knowledgeable about EMR charting, medication administration and interdisciplinary collaboration focused on optimizing patient care and support. Quality-focused and efficiency-driven leader.
Overview
11
11
years of professional experience
Work History
Prior Authorization Nurse - Care Review Clinician
Molina Healthcare
03.2024 - 08.2024
- Expedited urgent requests for prior authorization, ensuring timely access to critical medical treatments.
- Proficient in Panorama , EzCap , UMPortal , and Matrix programs.
- Proficient in Microsoft programs including but not limited to Microsoft word, Exel, Powerpoint.
- Provided exceptional customer service to both patients and healthcare professionals, addressing concerns related to the prior authorization process.
- Maintained detailed records and documentation related to prior authorization requests, ensuring accurate tracking and reporting for both internal and external stakeholders.
- Participated in interdisciplinary team meetings, collaborating with other healthcare professionals to ensure seamless coordination of care for patients requiring prior authorizations.
- Ensured accurate data entry into electronic health record systems, resulting in improved tracking of prior authorization statuses.
- Collaborated with healthcare providers to ensure accurate submission of required documentation for timely authorizations.
- Worked closely with case managers to facilitate appropriate utilization of healthcare resources through the prior authorization process.
- Educated patients on their insurance benefits, helping them understand their coverage and limitations regarding specific procedures or medications.
- Improved patient satisfaction by providing clear communication regarding insurance approvals and denials.
- Demonstrated commitment to professional development by participating in ongoing training opportunities related to the field of Prior Authorization nursing.
- Conducted thorough reviews of medical records, identifying necessary documentation to support prior authorization requests.
- Promoted a culture of continuous improvement within the Prior Authorization department by regularly reviewing processes and making recommendations for optimization.
- Assisted in maintaining compliance with changing regulations and policies by staying up-to-date on industry trends and best practices.
- Proactively identified potential barriers to approval, implementing strategies to address these challenges before they impacted patient care.
- Evaluated patient histories, complaints, and current symptoms.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Accomplished multiple tasks within established timeframes.
- Maintained thorough knowledge of insurance plan requirements, facilitating accurate and timely completion of authorization forms.
- Evaluated clinical criteria for approval or denial of services requiring pre-authorization.
- Responded to inquiries from healthcare providers regarding prior authorization requests.
- Monitored pending cases closely, proactively following up on outstanding documentation needed for successful approval outcomes.
Utilization Review Nurse
Network Medical Management
01.2020 - 06.2023
- Performed prior authorization review of services requiring notification.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Supervised and maintained all utilization review documentation through UMPortal & EZcap.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Evaluated patient histories, complaints, and current symptoms.
Licensed Vocational Nurse
Affinity Healthcare Center
10.2016 - 12.2019
- In charge of direct patient care as directed by facility protocol and under the supervision of the Registered Nurse in a Sub - Acute setting. Experience includes working with persons that have special needs such as ventilator dependence, tracheostomy and it’s appropriate suctioning, gastrostomy tube, enteral feeding, oxygen therapy, diabetic control, pain management, administering medication as ordered, and assisting Registered nurse's needed tasks.
- After hours receptionist. Includes phone management and directing incoming calls to the appropriate stations and faxing important documents through out night to interdisciplinary team and specialties.
- After hour admissions for Sub-Acute including following up with on-call doctors for order verification, data entry into EMAR (MatrixCare), follow through with pharmacy for medication dispensing.
- Assisting Case Manager and DON with PASRR entry, chart auditing, psychotropic summaries and obtaining appropriate consents.
- Supervising Certified Nursing Assistants during the shift and noting down any deficiencies with appropriate action taken.
- Point of contact for the Sub -Acute unit during the shift for any and all issues or inquiries.
- Cared for wounds, provided treatments, and assisted with procedures.
- Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
- Assessed patients' temperature, pulse, and blood pressure and recorded in electronic medical records.
- Documented patient vitals, behaviors and conditions to communicate concerns to supervising nurse.
- Documented accurate and complete patient information to address patient problems and expected outcomes.
- Collaborated with interdisciplinary team of healthcare and social service providers to address patients' needs through effective intervention and care planning.
- Assisted with admissions, appointments, transfers, and discharges.
- Responded to patient requests with appropriate clinical and personal assistance.
- Gathered lab specimens, ordered testing, and interpreted results to diagnose patients.
- Used aseptic techniques to provide sterilized wound care and dressing applications.
- Administered controlled narcotics, inserted IVs, and performed catheterizations.
- Performed routine evaluations of each patient's status, needs, and preferences.
- Delivered updates in patient status to charge nurse, recording changes in medical records.
- Monitored, tracked, and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.
- Coordinated patient transfers to other facilities.
- Managed various general office duties such as answering multiple telephone lines, completing insurance forms, and mailing monthly invoice statements to patients.
Licensed Vocational Nurse
Longwood Manor Convalescent Hospital
07.2013 - 10.2016
- Cared for wounds, provided treatments, and assisted with procedures.
- Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
- Assessed patients' temperature, pulse, and blood pressure and recorded in electronic medical records.
- Charge nurse in Sub-Acute unit under the direct supervision of the Registered Nurse supervisor. In charge of direct patient care which includes medication administration, gastrostomy care, tracheostomy care, DM management, pain management.
- Assisted in scheduling LVN and CNA with DSD and ADON.
- Managed various general office duties such as answering multiple telephone lines, completing insurance forms, and mailing monthly invoice statements to patients.
- Circulated assigned floor to measure and record patients' fluid and food levels, implementing measures to promote healthy intake and output as necessary.
- Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.
- Coordinated patient transfers to other facilities.
- Provided diagnosis information, treatment possibilities, disease management tips and wound care advice to patients, loved ones and caregivers.
- Helped long-term care residents with bathing, dressing, feeding, and other daily living activities.
- Evaluated patient histories, complaints, and current symptoms.
- Provided patient education on health care issues and prescribed medications.
- Reviewed patient history to verify conditions and current medications.
- Administered medications and injections to patients.
Education
High School Diploma -
Manual Arts Senior High School
Los Angeles, CALicense Vocational Nursing - Vocational Nursing
Concorde Career College
North Hollywood, CA05.2023
Associate Degree in Nursing - Healthcare Management
Healthcare Career College
Paramount, CA03.2020
Skills
- Patient Admission
- Determine Medical Necessity
- Benefits Guidelines
- Obtaining Authorizations
- Discharge Planning Coordination
- Patient Data Management Systems
- Utilization Review
- Record Analysis
- Office Support
- CPT Coding
- Healthcare Personnel Supervision
- Specialized Healthcare Referrals
- Unit Oversight
- Manage Cases
- Patient Care Oversight
- Office Administration
- Medical Billing
- Appointment Scheduling
- Medical Filing
- Policy and Procedure Adherence
- Clinical Staff Management
- Administrative and Office Support
Languages
English
Native or Bilingual
Spanish
Native or Bilingual
Timeline
Prior Authorization Nurse - Care Review Clinician
Molina Healthcare
03.2024 - 08.2024
Utilization Review Nurse
Network Medical Management
01.2020 - 06.2023
Licensed Vocational Nurse
Affinity Healthcare Center
10.2016 - 12.2019
Licensed Vocational Nurse
Longwood Manor Convalescent Hospital
07.2013 - 10.2016
High School Diploma -
Manual Arts Senior High School
License Vocational Nursing - Vocational Nursing
Concorde Career College
Associate Degree in Nursing - Healthcare Management
Healthcare Career College
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