Hi, I’m
Jasmin Rivera
Plant City,FL
Summary
Healthcare professional with substantial experience in utilization review and patient care management. Known for precision in evaluating patient treatment plans and making critical decisions to optimize resource use. Valued team collaborator with focus on achieving impactful results and adapting to dynamic healthcare environments.
Overview
10
years of professional experience
Work History
Commonwealth Care Alliance
Utilization Review Nurse
09.2020 - Current
Job overview
- Collecting clinical information necessary for preauthorizing services, assessing medical necessity, and determining the appropriateness of treatment settings
- Conduct various types of reviews, including pre-certification, inpatient, retrospective, and out-of-network reviews
- Review inpatient admissions and clinical information to determine the appropriate level of care required for each member
- Responsible for conducting inpatient reviews and utilizing InterQual to assess whether medical necessity criteria are met
- Work with patients who are chronically ill, in long-term acute care (LTAC), or acute care patients
- Collaborating with healthcare providers, including doctors, hospitals, specialists, and case managers, to ensure that patients are receiving appropriate care
- Communicate with providers telephonically and reach out to patients to inform them of approval or denial decisions regarding their care
- Expertise in acute inpatient appeals, ensuring compliance with medical necessity criteria and optimizing patient care outcomes.
Commonwealth Care Alliance
RN Case Manager/Care Partner
02.2017 - 09.2020
Job overview
- Served as the primary point of contact for members, responsible for coordinating all aspects of their care, acting as an advocate, and ensuring they receive the necessary services by connecting them within the community
- Managed a caseload of 65-80 cases within the community setting
- Conducted telephonic assessments with patients, identifying their needs
- The total caseload ranged from 200-250 cases
- Collaborated with other healthcare team members as needed, including behavioral health specialists, long-term care providers, and other specialists, based on the individual needs of each patient
- Coordinated and advocated for a member's care plan, which includes utilizing the Minimum Data Set (MDS) assessment to comprehensively understand a member's medical, functional, cognitive, psychosocial, and mental health needs
Guardian Healthcare
Home Health Registered Nurse
08.2015 - 01.2017
Job overview
- Provided compassionate home care, ensuring patients received personalized treatment plans
- Collaborated with healthcare teams to optimize patient outcomes and enhance quality of life
Holyoke Rehab
Psychiatric Registered Nurse
12.2014 - 08.2015
Job overview
- Provided direct nursing care to patients with mental health disorders, including assessing their condition, administering medications, developing treatment plans, managing crisis situations
Willimansett East Nursing Home
Registered Nurse-Skilled Nursing
10.2014 - 12.2014
Job overview
- Responsible for assessing, planning, implementing, and documenting comprehensive nursing care for residents
Education
Our Lady of the Elms CollegeChicopee, MA
Bachelor Of Science Degree from Nursing
Skills
- InterQual criteria
- Clinical assessment
- Healthcare regulations
- Communication
- Compliance procedures
- Interpersonal and written communication
- Prior authorization
- Quality improvement
Additional Information
- LICENSES: , Registered Nurse License in MA, Florida’s Nurse Licensure Compact, and California RN License.
Languages
English
Native or Bilingual
Certification
- Registered Nurse License (RN) - State Board of Nursing.
Availability
See my work availability
Not Available
Available
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Utilization Review Nurse
Commonwealth Care Alliance
09.2020 - Current
RN Case Manager/Care Partner
Commonwealth Care Alliance
02.2017 - 09.2020
Home Health Registered Nurse
Guardian Healthcare
08.2015 - 01.2017
Psychiatric Registered Nurse
Holyoke Rehab
12.2014 - 08.2015
Registered Nurse-Skilled Nursing
Willimansett East Nursing Home
10.2014 - 12.2014
Our Lady of the Elms College
Bachelor Of Science Degree from Nursing
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