Isabel Salazar
Fontana,CA
Summary
Dynamic Medical Claim Review Nurse with proven expertise at SCAN Healthplan in enhancing claim accuracy and compliance. Skilled in data analysis and effective communication, I have successfully streamlined processes and resolved disputes, driving quality improvement initiatives and ensuring adherence to regulatory standards. Committed to delivering optimal care through collaboration and problem-solving.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Medical Claim Review Nurse
SCAN HEALTHPLAN
10.2022 - Current
- Reviewed post services for concurrent and emergent claims, ensuring accuracy and compliance.
- Resolved appeals and disputes related to rendered services efficiently.
- Analyzed service claims to identify potential discrepancies or errors.
- Facilitated communication between departments for seamless appeal resolution.
- Streamlined claim review processes to enhance accuracy and speed.
- Investigated disputes promptly to uphold service standards.
- Collaborated with teams to address emerging issues in service claims.
Care Manager- Denial Nurse
Optum
07.2022 - 10.2022
- Executed all responsibilities of UM nurse, ensuring compliance with established guidelines.
- Reported findings to Utilization Management leadership promptly and accurately.
- Composed denial letters adhering to federal, state, health plan, and NCQA regulations.
- Constructed clear denial notices specific to members' conditions and requests.
- Ensured denial reasons were articulated at appropriate reading levels for comprehension.
- Verified that UM nurse reviewers referenced correct benefits and guidelines relevant to denials.
- Evaluated out-of-network and tertiary denials for network accessibility.
- Collaborated with UM compliance to enhance quality improvement initiatives.
Prior Authorization Case Manager
Regal Medical Group, IPA
07.2016 - 06.2022
- Promoted quality and cost-effectiveness of medical care through clinical acumen and adherence to policies.
- Facilitated appropriate care by applying principles of medical management for timely access.
- Communicated daily with providers, staff, and health plans regarding referral authorization issues.
- Collaborated with PACM colleagues, pre-auth coordinators, case managers, Medical Directors, and network management.
- Researched alternative care plans to direct members to optimal care settings.
- Acted as liaison among case managers, UM coordinators, contracted providers, members, and families when needed.
- Performed reviews based on outpatient indicators to evaluate completeness and consistency of care plans.
- Maintained regulatory turnaround time standards in compliance with guidelines.
LVN Charge Nurse
Claremont Care Center
01.2008 - 05.2016
- Performing nursing duties within guidelines of hospital policies and procedures, caring for high risk/high profile patients with multiple medical conditions and devices attached to patients’ body.
- Assisting with Case Management, weight variances, Admissions, Discharge planning, COC, Patient teaching, Assessments, and Med Administration, Wound care.
- As a Licensed Vocational Nurse we observed and recorded patients: behavior, responses to treatment and medications while sharing the information with the treatment team which provided input for the changes in the patient’s treatment programs.
- Reporting lab values, Discharge planning, Family/Patient Education.
- Admissions of new patients as well as dealing with end-of-life patients (Hospice care) and Palliative care.
- Managed admissions of new patients while providing compassionate care for end-of-life and hospice cases.
LVN Charge Nurse
Fernview Convalescent Hospital
01.2003 - 01.2008
- Skilled Nursing Hospital: Performing nursing duties within guidelines of hospital policies and procedures, caring for high risk/high profile patients with multiple medical conditions and devices attached to patients’ body.
- Assisting with Case Management, weight variances, Admissions, Discharge planning, COC, Patient teaching, Assessments, and Med Administration, Wound care.
Education
Nursing Certificate -
Citrus College
01.2002
Skills
- Claim review
- Service compliance
- Utilization management
- Denial letter composition
- Medical coding
- Care coordination
- Effective communication
- Problem solving
- Team collaboration
- Time management
- Data analysis
- Regulatory adherence
- Quality improvement
Certification
- CPR, 06/2025
- Infection Control
- BLS/CPR
- IV Certified
References
Available upon request
Personal Information
Title: Licensed Vocational Nurse
Languages
Spanish
Professional
Timeline
Medical Claim Review Nurse
SCAN HEALTHPLAN
10.2022 - Current
Care Manager- Denial Nurse
Optum
07.2022 - 10.2022
Prior Authorization Case Manager
Regal Medical Group, IPA
07.2016 - 06.2022
LVN Charge Nurse
Claremont Care Center
01.2008 - 05.2016
LVN Charge Nurse
Fernview Convalescent Hospital
01.2003 - 01.2008
Nursing Certificate -
Citrus College