Jay Vee Gopez, RN, CRC
Indianapolis,Indiana
Summary
Experienced individual well-versed in providing patientcentered nursing care in a variety of settings. Proven ability to manage complex cases and create evidencebased plans of care. Demonstrated expertise in developing and delivering patient education programs and collaborating with interdisciplinary teams to improve patient outcomes.
Overview
14
14
years of professional experience
1
1
Certification
Work History
Clinical Nurse
IU Health Methodist Hospital
Indianapolis, Indiana
06.2023 - Current
- Assigned in Adult General Psychiatric Inpatient Unit
- Recorded comprehensive patient histories and coordinated treatment plans with multi-disciplinary team members.
- Participated in interdisciplinary team meetings to discuss treatment plans and goals for each patient.
- Assessed client responses to medication regimes and reported any adverse reactions.
- Assisted with crisis intervention when needed.
- Maintained accurate documentation of patient care services provided in accordance with agency policy and procedures.
HEDIS Review and QA Nurse
Cotiviti
Utah, USA
01.2024 - 05.2024
- Reviewed provider documentation to evaluate compliance with quality measure criteria.
- Developed and maintained relationships with providers to ensure accurate completion of HEDIS measures.
- Performed HEDIS data collection and abstraction from medical records for multiple health plans.
- Evaluated clinical information systems to ensure accuracy of data collection and reporting procedures.
- Assisted with the development, implementation, and maintenance of audit processes related to HEDIS measures.
Registered Nurse
Greenwood Healthcare Center
Greenwood, Indiana
10.2022 - 06.2023
- Provided nursing care to elderly residents including medication administration, wound care, and symptom management.
- Ensured compliance with all federal, state and local regulations governing long-term care facilities.
- Collaborated with physicians and other healthcare professionals to develop interdisciplinary treatment plans for residents.
- Maintained accurate documentation of patient's progress in the electronic medical record system.
- Responded quickly to any changes in a resident's condition or behavior by initiating appropriate interventions or notifying the physician and healthcare team member immediately.
HEDIS Review Nurse
Cotiviti
Utah, USA
01.2023 - 05.2023
Medical Management Nurse
Anthem Blue Cross Blue Shield
Taguig City, Philippines
01.2020 - 07.2022
- Assessed patient eligibility for services and benefits according to insurance policies and guidelines.
- Analyzed prior authorization requests for accuracy and completeness before submission to payer.
- Documented all activities related to utilization management in the electronic medical record system.
- Conducted utilization reviews, concurrent reviews, authorization requests and discharge planning.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
Utilization Review Nurse/Medical Coder
Shearwater Health
Taguig City, Philippines
09.2014 - 01.2020
- Assisted physicians in the identification of appropriate diagnosis codes based on documentation in the medical record.
- Reviewed medical records to identify and code diagnoses in accordance with ICD-10 guidelines.
- Documented risk adjustment codes into electronic health record systems, ensuring accuracy of data entry.
- Maintained current knowledge of changes related to ICD-10 and CMS regulations.
- Conducted chart reviews to identify any missing or incomplete information necessary for accurate coding.
- Determined medical necessity and cost-effectiveness of services through utilization review processes.
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Monitored pre-authorization requests to ensure that all necessary information was received prior to approval or denial of services.
Registered Nurse, Medical-Surgical Unit
Sta. Monica General Hospital
Marikina City, Philippines
09.2010 - 01.2013
Education
Bachelor of Science (B.S.) in Nursing -
Our Lady of Fatima University
03.2010
Skills
- HCC Coding Knowledge
- Risk Adjustment Principles
- ICD-10 Proficiency
- Diagnostic Coding Accuracy
- Deadline Oriented Approach
- Clinical Documentation Review
Certification
- Registered Nurse of State of Indiana
- Certified Risk Adjustment Coder
- Crisis Prevention and Intervention (CPI)
- Basic Life Support
Timeline
HEDIS Review and QA Nurse
Cotiviti
01.2024 - 05.2024
Clinical Nurse
IU Health Methodist Hospital
06.2023 - Current
HEDIS Review Nurse
Cotiviti
01.2023 - 05.2023
Registered Nurse
Greenwood Healthcare Center
10.2022 - 06.2023
Medical Management Nurse
Anthem Blue Cross Blue Shield
01.2020 - 07.2022
Utilization Review Nurse/Medical Coder
Shearwater Health
09.2014 - 01.2020
Registered Nurse, Medical-Surgical Unit
Sta. Monica General Hospital
09.2010 - 01.2013
Bachelor of Science (B.S.) in Nursing -
Our Lady of Fatima University
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