Janie Ramirez
Menifee,CA
Summary
Compassionate Nurse Case Manager offering 20 years of experience working with patients and families to facilitate smooth transitions following discharge from medical facilities. Committed to working collaboratively with health plan, leadership and department coordinators to achieve highest quality of patient satisfaction. Well-versed in developing individualized care plans and advocating patient welfare.
Skilled in creating and implementing processes to improve patient care and cultivate support teams.
Hardworking and passionate job seeker with strong organizational skills eager to secure a registered nurse position. Ready to help team achieve company goals.
Highly organized case manager with several years of experience as registered nurse. Offering a proven history of successfully advocating for patients and working with practitioners. Passionate about delivering quality care and facilitating efficient healthcare coordination.
Overview
18
18
years of professional experience
Work History
UR Nurse Case Manager
Rady's Children's Hospital
08.2024 - Current
- Educated patients and caregivers on healthcare protocols and processes.
- Served as a liaison between patients and various support services such as financial assistance programs, community resources, and mental health counseling to ensure holistic care was provided.
- Increased referral rates by providing excellent service and building meaningful relationships with patients and caregivers.
- Collaborated with healthcare leaders and physicians to support and offer resources in performance of duties to maintain high-quality and efficient patient care.
- Managed support services and fostered communication among social workers, therapists, hospital staff, and patients.
- Promoted continuity of care by coordinating with healthcare providers, social workers, and family members in the development of discharge plans.
- Applied critical thinking skills during case reviews to identify potential risks or challenges before they escalated into larger issues.
- Enhanced interdisciplinary team communication, ensuring timely and accurate updates on patient progress.
- Facilitated smooth transitions between healthcare settings by effectively communicating pertinent information to receiving facilities or home health agencies.
- Implemented aspects of patient care under physician orders and sought clarification when needed to promote safety, quality and cost-efficient care.
- Developed strong relationships with patients, families, and healthcare providers, fostering trust and open communication resulting in improved satisfaction scores.
- Managed caseloads efficiently, prioritizing high-risk cases while ensuring all patients received appropriate attention and support.
- Advocated for patient needs, addressing concerns with healthcare providers and insurance companies to ensure optimal care was received.
- Evaluated patient histories, complaints, and current symptoms.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Maintained professional competence by staying current on industry trends, best practices, and regulatory requirements specific to utilization review nursing.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Served as a vital liaison between patients, healthcare providers, and insurance companies, fostering effective communication and coordination among all parties involved in the care process.
- Streamlined the case management process by effectively prioritizing high-risk cases for timely intervention and followup.
- Supervised and maintained all utilization review documentation through Software.
- Enhanced patient satisfaction by collaborating with interdisciplinary teams to develop individualized care plans, ensuring appropriate level of care.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Collaborated with insurance companies to verify coverage, clarify benefits, and facilitate authorization for medical services, reducing delays in patient care delivery.
- Optimized hospital stays by monitoring admissions for appropriateness based on established clinical guidelines while considering each patient''s unique circumstances.
Registered Nurse Case Manager
UnitedHealthcare
02.2023 - 07.2024
- Effectively communicated with physicians regarding patient needs, performance, medications and changes.
- Completed initial assessments of patients and family to determine and address individual home care needs. ·
- Coordinated with interdisciplinary professionals to develop plans of care, administer tests and monitor patient status.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Evaluated healthcare needs, goals for treatment and available resources of each patient and connected to optimal providers and care.
- Responded promptly and professionally to patient questions and concerns.
- Created individualized care plans based on nursing diagnosis and incorporated appropriate nursing methods to achieve positive outcomes.
- Participated in patient and family planning process, as well as provided instructions and addressed question and concerns.
- Liaised with physicians regarding patient needs, performance and changes.
- Conducted regular re-evaluations to address changes in needs and conditions, introducing revisions to care plans.
- Took active role in patient and family planning process, detailing instructions and responding appropriately and effectively to questions and concerns.
- Educated patients and loved ones about different treatment options and outside care approaches to reduce burden on hospital resources.
Utilization Review Nurse
Valley Health Systems
11.2022 - 07.2024
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed admission reviews based for medical necessity based upon interqual specification.
- Obtained authorizations from multiple insurance carriers for various levels of care.
- Supervised and maintained all utilization review documentation through interqual.
- Performed prior authorization review of services requiring notification.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
Nurse Case Manager
Elevance Health
07.2012 - 12.2022
- Educated patients and caregivers on healthcare protocols and processes.
- Developed and modified patient care plans and assisted interdisciplinary team in identifying client needs and goals to determine priorities of care.
- Managed support services and fostered communication among social workers, therapists, hospital staff and patients.
- Collaborated with healthcare leaders and physicians to support and offer resources in performance of duties to maintain high-quality and efficient patient care.
- Gathered and recorded patient health information and data to assess, identify and manage characteristics that affect care outcome.
- Analyzed patient responses to medications, therapies and variances in plans of care.
- Educated family members and caregivers on patient care instructions.
- Evaluated patient histories, complaints and current symptoms.
- Advocated for and strived to protect health, safety and rights of patient.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
- Accurately documented treatment, medications and IVs administered, discharge instructions and follow-up care.
- Explained course of care and medication side effects to patients and caregivers in easy-to-understand terms.
- Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
- Observed and documented patient factors such as diets, physical activity levels and behaviors to understand conditions and effectively modify treatment plans.
- Assessed and evaluated mental health needs, working with multidisciplinary team to initiate, manage and modify individualized care plans.
- Implemented care plans for patient treatment after assessing physician medical regimens.
- Conveyed treatment options, diagnosis information and home care techniques to patients and caregivers to continue care consistency.
- Collaborated with leadership to devise initiatives for improving nursing satisfaction, retention and morale.
NICU Case Manager
Alere Home Monitoring
12.2011 - 07.2012
- Helped patients receive appropriate, high-quality care with reasonable results.
- Partnered with physicians, social workers, activity therapists, nutritionists and case managers to develop and implement individualized care plans and documented patient interactions and interventions in electronic charting systems.
- Identified care needs of individual patients and coordinated responses based on physician advice, insurance limitations and procedural costs.
- Evaluated treatment plans against individual goals and healthcare standards.
- Consulted with clinicians to devise and manage ongoing care plans for at-risk patients.
- Managed support services and fostered communication among social workers, therapists, hospital staff and patients.
- Increased referral rates by providing excellent service and building meaningful relationships with patients and caregivers.
- Educated patients and loved ones about different treatment options and outside care approaches to reduce burden on hospital resources.
- Reduced care costs without sacrificing quality through service coordination and multidisciplinary collaboration.
- Addressed delays in discharge, postponed procedures and discharge equipment unavailability.
Nurse Medical Management Reviewer Sr
WellPoint, Anthem Blue Cross
07.2006 - 12.2011
- Maintained accuracy, completeness and security for medical records and health information.
- Input data into computer programs and filing systems.
- Reviewed medical records for completeness and filed records in alphabetic and numeric order.
- Communicated effectively with staff, patients and insurance companies by email and telephone.
- Compiled electronic patient records covering conditions, treatments and diagnoses.
- Processed patient admission and discharge documentation.
- Created new physical and computer-based files.
- Handled high-volume data entry of demographics, disease etiology and extent and associated procedures or treatments.
- Supported smooth admission and discharge processes by handling associated documents.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed admission reviews based for medical necessity based upon specification.
- Supervised and maintained all utilization review documentation through Software.
- Performed prior authorization review of services requiring notification.
- Accurately documented treatment, medications and IVs administered, discharge instructions and follow-up care.
- Advocated for and strived to protect health, safety and rights of patient.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
- Promoted patient and family comfort during challenging recoveries to enhance healing and eliminate non-compliance problems.
- Assessed and evaluated mental health needs, working with multidisciplinary team to initiate, manage and modify individualized care plans.
- Utilized Software to manage and confirm patient data, such as insurance, demographic and medical history information.
Education
Bachelors Degree In Nursing - Nursing
United States University
Chula Vista, CA03.2021
Associate Degree In Nursing - Nursing
Ventura College
Ventura, CA12.2003
Skills
- Patient and Caregiver Education
- Clear Patient Communication
- Community Program Referral
- Time Management
- Active Listening
- Complex Problem-Solving
- Referral Coordination
Languages
Spanish
Native or Bilingual
Timeline
UR Nurse Case Manager
Rady's Children's Hospital
08.2024 - Current
Registered Nurse Case Manager
UnitedHealthcare
02.2023 - 07.2024
Utilization Review Nurse
Valley Health Systems
11.2022 - 07.2024
Nurse Case Manager
Elevance Health
07.2012 - 12.2022
NICU Case Manager
Alere Home Monitoring
12.2011 - 07.2012
Nurse Medical Management Reviewer Sr
WellPoint, Anthem Blue Cross
07.2006 - 12.2011
Bachelors Degree In Nursing - Nursing
United States University
Associate Degree In Nursing - Nursing
Ventura College
Similar Profiles
Aaliyah AdamsAaliyah Adams
Administrative Clerk at Rady's Children's HospitalAdministrative Clerk at Rady's Children's Hospital
Samantha TorresSamantha Torres
CNA at Rady's Children's HospitalCNA at Rady's Children's Hospital
Alicia CasillasAlicia Casillas
Environmental Services Attendant at Rady's Children's HospitalEnvironmental Services Attendant at Rady's Children's Hospital