Jayne Rodriguez-Hernandez
San Antonio
Summary
Highly motivated professional LPN with over 9 years experience in healthcare insurance industry offer clinical review and analysis of patient records meant to bridge care delivery, plan administration, and cost management for employer-sponsored health plans. I have experience in collaborating with internal teams and external vendor partnerships serving as a clinical liaison to assure care delivery is appropriate and better outcomes are achieved for both the plan and its employees while reducing unnecessary spend and cost containment. Detail-oriented individual with exceptional communication and project management skills. Proven ability to handle multiple tasks effectively and efficiently in fast-paced environments
Overview
13
13
years of professional experience
Work History
Utilization Review Nurse Case Manager
UnitedAg
2021.06 - 2024.11
- Coordinated medical services with outside UM companies, stop loss carriers, PBM vendors, and other medical providers.
- Facilitates and tracks external medical reviews, including the federal IRO process
- Primary source for claims, requests for medical reviews and all member/provider appeals and grievances within regulatory guidelines.
- Oversaw cases of critical or high-profile/high-cost claimants for health plan, maintaining close communication with stop loss team to monitor cost thresholds.
- Collaborated with underwriting and stop loss teams to research cost estimates for care, contributing to risk assessments for new and renewing groups.
- Experience in Renal transplant program and identifying potential cases for internal/external consideration
- Experience in 3rd party vendor for high-cost infusions, identifying potential cases for internal/external consideration
- Facilitate all coordination of medical services with outside UM companies, stop loss carriers, PBM vendor and other medical providers as needed.
- Facilitate all our Mexico panel medical reviews and preauthorizations with ability to translate request in English
National Director of Case Management
Caprock Health Plan
2018.05 - 2021.06
- Facilitated onboarding for new UR/CM vendor Valenz, establishing UR review criteria to enhance service evaluation.
- Coordinated project activities among teams to ensure smooth workflow. in transitioning groups from UR/CM vendors MCC/HINES to new UR/CM vendor Valenz
- Supported in onboarding process for new UR/CM vendor Valenz and in establishing UR review criteria of services.
- Identify LCM opportunities to increase revenue by daily/weekly review of ER report, trigger diagnosis report, precert reports, red flag alerts.
- Liaison between UR vendor and transplant carrier when applicable/cost containment for all transplant cases new/ongoing
- Coordinated with Carrier Services referrals to case management for members approaching or surpassing specifications for cost-to-care estimates used in risk assessments.
- Support Carrier Services on medical/clinical care approaches, standards of care, and help research data in support of the underwriting process.
- Serve as the primary resource for claims operations for medical necessity reviews and assessments by applying knowledge of clinical and industry guidelines.
- Facilitate review requests and ensure clear, concise, evidence-based rationales have been provided in support of all recommendations and/or determinations.
- Engaged stakeholders in discussions to gather insights for policy improvements. and provide recommendations for internal policy changes for claims processing, reviews and plan build documents.
- Coordinated and tracked external medical reviews with clinical review vendors to support medical determinations and appeals, including federal IRO processes.
- Meet with internal teams such as Claims Operations, Compliance, Client Services, and Carrier Services to provide overviews and updates on catastrophic claimants, industry trends, and ongoing high-profile case management cases.
Nurse Case manager
Caprock Health Plan
2017.12 - 2018.05
- Conducted outreach to members with trigger diagnoses to assess and address case management needs.
- Outreach to members identified with trigger diagnosis to assess for case management needs.
- Acted as liaison among members, families, and healthcare providers to ensure coordinated care.
- Tight tracking and case management of all kidney disease members to include communication with transplant carrier and cost containment.
- Coordinate and facilitate all UR requests to UR vendors.
- Managed case tracking for all kidney disease members, facilitating communication with transplant carriers to optimize care and control costs.
Quality HEDIS Nurse Coordinator
WellMed UHG (contract position/Maxim Staffing)
2016.01 - 2017.12
- Analyze and trend HEDIS/STAR rates, identify barriers to improvement of rates and create interpretive exhibits.
- Navigate through Ecw and DataRap to abstract medical record documentation supportive of HEDIS/STAR measures
- Conducted chart chases for specific insurance products and measures.
- Executed various related duties and adapted to mid-day reassignments.
- Attended weekly department meetings to discuss ongoing projects and objectives.
- Analyzed data for integrity and deficits, documenting findings to enhance quality measures.
- Supports and assists PCPs/clinics with quality data collection.
- Obtain quality detail report and flag patient’s charts with the missing measures.
- Provides reports and monitors performance at local level.
- Supported PCPs and clinics in quality data collection to ensure accurate measure reporting.
- Participation in weekly department meetings
- Engage PCP and clinic staff in developing strategies to close quality gaps.
- Maintains education/knowledge base of HEDIS/STAR standards and guidelines.
- Perform all other related duties as assigned and flexible in mid-day reassignments when required.
Physician Liaison/Marketer & Field nurse
Criterion Health Care Incorporated (business sold)
2015.06 - 2016.02
- Managed outreach initiatives to drive growth and expansion in San Antonio area
- Developed promotional materials and conducted drop-ins, lunch n' learns, and meetings with multiple providers in San Antonio area
- Liaison for home office in Rio Grande Valley and all referring providers in San Antonio.
- Established and maintained an organized database of current and potential referral sources to enhance provider engagement.
- Provided nursing care to patients in various settings.
- Delivery of medical needs and treatment for patients according to an active plan of care
- Skilled in thorough head to toe assessments
- Administration of prescribed medication, treatments, and therapies
- Coordination of care with providers, pharmacies, DME, hospitals/clinics and other ancillary facilities
- Educated and trained family members on care protocols.
UR Nurse
Prospect Health Services
2014.10 - 2015.06
- Received, reviewed, and complied authorization requests for appropriateness before submitting cases for Reviewing medical director.
- Contacted provider offices to obtain additional clinical information for medical review by medical director to establish medical necessity and appropriate standard of care.
- Utilized logic and reasoning to determine appropriate HEDIS measure, CMS guideline criteria or Milliman as applicable.
- Conducted research on individual cases to support review requests effectively.
- Compiled and presented clinical packets for medical director's review to facilitate informed decision-making.
- Provided verbal notifications to providers and members regarding determination outcomes to requesting provider(s) and member of determination outcomes.
- Faxed documentation to requesting providers for timely communication to all requesting providers in addition to letter mailed.
- Coordinated communication with management regarding urgent issues and proposed enhancements.
- Coordinated initial screening for UM claim reviews through claim queue.
- Received and responded to telephone calls through the UM Phone Queue.
Program Specialist I/HRA intake
Superior Centene (Healthcare Scouts Agency contract position)
2013.10 - 2014.02
- Telephonic outreach to members to perform annual HRAs, identify any risks or barriers to care and refer to further internal resources (case management, social worker, pharmacy and/or DME)
- Developed and implemented program initiatives to enhance patient care services.
- Collaborated with cross-functional teams to streamline operational workflows and improve service delivery.
- Analyzed program data to identify trends, ensuring compliance with healthcare regulations and standards.
Care Review Clinician I / Appeals Nurse
Molina Healthcare
2012.01 - 2013.09
- All appeal clinical, reviewed for medical necessity using TMHP, Interqual or plan guidelines.
- Notified appealing parties, members, and providers of additional documentation required for appeal before presenting to MD for review.
- Communication to appealing party; member, provider/facility of any additional documentation identified as needed for appeal, prior to presenting for MD review.
- Presented appeal cases to Medical Directors for reconsideration, facilitating informed decisions on case overturns or upholding denials.
- Communicated outcomes of appeal requests accordingly to include options for upheld denials.
- Responded to calls from providers or members regarding appeal status and concerns from providers or member with regards to appeal status or concerns
- 8-10 case processed and reviewed per day.
- Engaged in scheduled department meetings to discuss updates and training in scheduled department meetings and/or trainings
- Cross-trained as denial & prior authorization nurse
Education
Certificate of Completion Licensed Vocational Nursing -
Victoria College
2002-01
High School Diploma - undefined
McAllen Memorial High School
1982-01
Skills
- 25 years Licensed Practical Nurse
- Unrestricted compact Practical Nurse Licensure Status: CURRENT
- 9 years experience in case management
- 14 years experience in medical insurance industry with prior authorizations, denials, appeals processes
- Experience with insurance metrics HEDIS, STARR, cost containment and subrogation
- Experience with TPAs ( self-funded/fully funded) and commercial insurance
- Experience in Health information technology, EMR, Microsoft Word, Microsoft office and Microsoft PowerPoint
- Experience with Find-A-Code, coding resource tool and DHCS Trilogy
- Experience in interpreting criteria for Medicare and summary plan descriptions (SPD) of insurance plans
- Strong interpersonal and problem-solving skills
- Professional written and verbal skills
- HIPPA compliant
- Bilingual in English/Spanish
- Interpersonal and written communication
- Managed care
- Medical coding
- Utilization management
- Telephonic nursing
- Compliance procedures
- Analytical thinking
- Strong clinical judgment
- Records analysis
- Utilization review
- Task prioritization
- Effective communication
- Organizational skills
Languages
Spanish
Professional Working
English
Native or Bilingual
Timeline
Utilization Review Nurse Case Manager
UnitedAg
2021.06 - 2024.11
National Director of Case Management
Caprock Health Plan
2018.05 - 2021.06
Nurse Case manager
Caprock Health Plan
2017.12 - 2018.05
Quality HEDIS Nurse Coordinator
WellMed UHG (contract position/Maxim Staffing)
2016.01 - 2017.12
Physician Liaison/Marketer & Field nurse
Criterion Health Care Incorporated (business sold)
2015.06 - 2016.02
UR Nurse
Prospect Health Services
2014.10 - 2015.06
Program Specialist I/HRA intake
Superior Centene (Healthcare Scouts Agency contract position)
2013.10 - 2014.02
Care Review Clinician I / Appeals Nurse
Molina Healthcare
2012.01 - 2013.09
High School Diploma - undefined
McAllen Memorial High School
Certificate of Completion Licensed Vocational Nursing -
Victoria College
+Event ID
- TSA-h7kP-H7Dt-S1KRk
- Hi Amy, I reviewed your proposal and wanted to provide you with some preliminary feedback. I am impressed with your plans for revamping our advertising campaign, and I like the suggestions you included about trying to appeal to a younger demographic. I do have some concerns regarding the cost of the proposed changes, and would like you to provide more detail as to the pricing structure. Are you available for a short conference call sometime in the next week? If there is a time that would work best for you and your team, please let me know. Thanks very much.
- Amy@acmecorp.com and Cc bill@acmecorp.com