Irca Cardoso Gomez, APRN, FNP-C, MSN

• Provided education on utilization management processes to staff members as needed.
• Ensured compliance with all regulatory requirements related to utilization management services.
• Analyzed trends in utilization data to identify opportunities for improvement in quality of care and cost containment measures.
• Oversaw daily workflow of utilization review cases and monitored completion of timely reviews.
• Maintained up-to-date knowledge base regarding changes in laws and regulations impacting Utilization Management functions.
• Monitored performance metrics related to utilization management outcomes such as length of stay and episode duration, readmission rates.
• Facilitated interdisciplinary meetings between Utilization Management staff and other departments as needed.
• Conducted audits of case files to ensure accuracy and completeness of documentation according to standards set forth by the organization.
• Reviewed denials for appropriateness according to policies, procedures, guidelines and regulations.
• Developed and maintained effective relationships with health plan partners, providers and internal stakeholders.
• Coordinated with other supervisors, combining group efforts to achieve goals.
• Interpreted and explained work procedures and policies to brief staff.
• Delegated work to staff, setting priorities and goals.
• Developed work schedules according to budgets and workloads, covering priority tasks.
• Trained employees on best practices and protocols while managing teams to maintain optimal productivity.
• Implemented departmental policies and standards in conjunction with management to streamline internal processes.
• Guided employees in handling difficult or complex problems.
• Discussed job performance problems with employees, identifying causes and issues to find solutions.
• Recruited, interviewed and selected employees to fill vacant roles.

• Perform Audits of nurse case management functions. Monitor selected patient progress and intervene as needed regarding timing, sequencing and resolving barriers to patient transition.
• Provide education/training with constructive feedback in the areas of computer literacy, utilization review and progression of care to new nurse case management team members. Maintain/update education manuals, choose and complete preceptor schedules.
• Act as a resource and collaborates with multidisciplinary team to minimize barriers to efficient delivery of care, denial avoidance, discharge planning and outcomes management.
• Function as a leader, accepting responsibility in a leader’s absence.
• Escalate issue to leadership and physician advisor as indicated.
• Direct the documentation of avoidable delays to nurse case management team.
• Assume coordination of care for designated caseload, as needed, including utilization review and progression of care.
• Maintain expertise in Interqual and MCG criteria and tutor nurse case management staff in appropriate applications.
• Collect, analyze and address variances from the plan of care/clinical pathway with other members of the healthcare team.
• Assist with developing evidence-based policies/procedures.
• Provide assistance with data collection and report/presentation.

• Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
• Coordinates with Healthcare team to achieve optimal efficient outcomes, decreasing length of stay (LOS) and avoiding delays/denied days.
• Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
• Contacted insurance carriers to obtain authorizations for services delivered to patients.
• Kept detailed documentation on all utilization reviews by using InterQual and MCG.
• Advocated for patient needs with interdisciplinary team and implemented outlined treatment plans.
• Identify delays in treatment or inappropriate utilization and serves as a resource.
• Trained and mentored new staff on best practices, and hospital policies.
• Referred cases to secondary review.
• Coordinates communication between payer and hospital physicians.

• Developed and initiated departmental goals, standards of performance, policies and procedures.
• Coordinated with Senior Director to develop programs targeting nurse education, overall departmental competencies, individual performance, patient safety and service-related issues.
• Serve as a liaison between external business partners, and internal team members providing clinical leadership of SNP clinical requirements including utilization management (UM), care management (CM), quality improvement (QI), appeals and other requirements outlined in the Model of Care.
• Identify and advise UM, CM, QI, and other operational leadership of trends, problems, and issues as well as recommended course of action; ensure timely communication; participate in the development and implementation of solutions.
• Encouraged high morale and staff retention through effective communication, prompt problem resolution, proactive supervisory practices and the facilitation of a proactive work environment.
• Employed active listening and interpersonal talents to effectively interact with various individuals, including physicians, patients and fellow employees.
• Collaborated with healthcare professionals to deliver high-quality patient care.
• Assigned case managers to monitor progress of patients after they left the hospital..
• Oversaw clinical operations and procedures while remaining current of federal and state regulations to ensure organization processes were fully compliant with new healthcare law requirements.
• Introduce new departmental policies and orient staff to facilitate adoption of changes.
• Evaluated the performance of staff nurses, contributing to their professional development.
• Maintained quality care systems, standards and HIPAA confidentiality.

• Clinical review of requests for authorization of pre and post services, including; transplant, hospital admissions, outpatient procedures/services, practitioner's in office procedures, oncology, radiology, medication, therapies (Speech, Feeding, Occupational and Physical), emergency ambulance ground/air, Orthotics and Prosthetics, Hearing Aide Services and Out-of-State Services Reviews.
• Preceptor lead for new hires, process engineering and staff mentoring. Managerial and clinical links between the department staff and department director. Act as a resource in identifying and/or solving administrative/operational problems.
• Applies authorization process (InterQual Medical Guidelines, process standards, policies, procedures, standard operating procedures and Medicaid guidelines).
• Work closely with Medical Director determining medical necessity when medical information provided does not support the nurse review process for giving an approval of services requested.
• Assistance with discharge planning incorporating Case management department and Community services.

• Delegate the shift’s tasks to all of the nurses in the unit and coordinate with physicians who might need assistance
• Complete patient assessments and triage, record patient histories, symptoms and observations.
• Establish and implement nursing care plans for each patient through assessment, development, activation
  and evaluation.
• Participate in patient case conferences and rounds.
• Perform nursing care following prescribed rules, policies, protocol and procedures.
• Identify problems, assist in data gathering, propose solutions and participate in evaluation of quality assurance issues.
• Work with patient and their families to provide in-hospital and after-hospital follow-up through teaching and referral.
• Participate in educational programs to maintain level of expertise.
• Participate in non-clinical assignments, which include maintaining records, preparing reports and/or serving on special committees. 
• Operate a variety of medical machinery and equipment.
• Administer treatment and medications.
• Maintain knowledge of outpatient resources.
• Develop discharge plans for patients

Lead Float Case Manager

• Documenting patients' case management plans and on-going activities.
• Identifying patients' insurance coverage or other sources of payment for services.
• Identifying and addressing patient risk factors and/or obstacles to care.
• Identifying patients needs, current services, and available resources, then connecting the client to services and resources to meet established goals.
• Communicating the care preferences of patients, serving as their advocate, and verifying that interventions meet the client's needs and goals of treatments.
• Screening patients and/or population for healthcare needs.
• Developing a patient-focused case management plan.
• Educating the patient/family/caregiver about the case management process and evaluating their understanding.

• Develop business strategies to raise our customers' pool, expand store traffic and optimize profitability.
• Supervising and guiding staff towards maximum performance. 
• Completed annual performance evaluation on staff.
• Meet sales goals by training, motivating, sectoring and providing feedback to sales staff.
• Ensure high levels of customers satisfaction through excellent service.
• Complete store administration and ensure compliance with policies and procedures.
• Maintain outstanding store condition and visual merchandising standards.
• Report on buying trends, customer needs, profits etc.
• Propose innovative ideas to increase market share.
• Conduct personnel performance appraisals to assess training needs and build career paths.
• Deal with all issues that arise from staff or customers (complaints, grievances etc).
• Be a shining example of well behavior and high performance.

• Completes an initial assessment of patient and family to determine home care needs. Provides a complete physical assessment and history of current and previous illness (es).
• Regularly re-evaluates patient nursing needs.
• Initiates the plan of care and makes necessary revisions as patient status and needs change.
• Develops a care plan which establishes goals, based on nursing diagnosis and incorporates therapeutic, preventive, and rehabilitative nursing actions. Includes the patient and the family in the planning process.
• Initiates appropriate preventive and rehabilitative nursing procedures.
• Administers medications and treatments as prescribed by the physician. Counsels the patient and family in meeting nursing and related needs.
• Provides health care instructions to the patient as appropriate per assessment and plan.
• Identifies discharge planning needs as part of the care plan development and implements prior to discharge of the patient.
• Communicates with the physician regarding the patient's needs and reports and changes in the patient's condition; obtains/receives physicians orders as required.
• Ensures that arrangements for equipment and other necessary items and services are available.
• Instructs, supervises and evaluates home health aide care provided every fourteen day