Jessica Aguilar

• Contributed to achieving optimal service delivery through coordinated services management
• Provided education on insurance coverage, financial resources, and available support services to aid patients in navigating the healthcare system
• Advocated for patients in interactions with healthcare providers, insurance plans, and community resources
• Collaborated with healthcare providers, patients, and families to ensure smooth transitions of care during discharge planning
• Offered guidance and knowledge to patients and their families regarding medical conditions, treatments, as well as the cruciality of complying with continuous treatment plans

· Determined the medical necessity of services using a predefined set of criteria

· Suggested recommendations to enhance member care by partnering with Providers.

· Assessed, reviewed, and applied necessary criteria demonstrating understanding; Coordination with Medical Directors for services that required additional review or did not meet criteria

· Consistently achieved departmental Turn Around Time, daily productivity targets, and service level expectations

Demonstrated knowledge in process flow and UM such as prior authorizations, concurrent authorizations, clinic appeals, and grievance reviews. Proficient in policies, procedures, Medicare, HIPAA, and NCQA standards.

• Conducted analysis of data, identified potential data integrity issues, and documented findings
• Conducted trend analysis and audits to identify barriers hindering rate improvements
• Closely worked with local leadership in the execution of quality strategies
• Generated and analyzed performance reports at the local level
• Enhance communication channels and functionality between market and corporate departments
• Ensured consistent education and knowledge on HEDIS/STARs standards and guidelines

• Coordinate patient care under the direction of Providers, Registered Nurses and policies encompassing referrals, transition visits, medications, procedures and follow-up
• Sourced chief complaints and symptoms from patients via telephone with precision
• Contributed to the implantation of established education plans for patients and their families facing common health challenges
• Maintained oversight of quality measures for physician patient panels
• Participated in executing quality strategies in alignment with monthly and yearly metrics set by management
• Ensures knowledge of latest HEDIS/STARs standards and guidelines

• Managed an Oncology Specialty center as a Lead Nurse
• Provided guidance and supervision to Medical Assistants and LVNs regarding outpatient care, medication, and scheduling
• Delivered patient instruction, dispensed medicines, and directed both in-person visitors as well as callers on an as-needed basis
• Administered IV Therapy including fluids, IV iron, and other prescribed therapeutic drugs
• Supported medical professionals in performing surgical procedures, including Bone Marrow Biopsies and Therapeutic Phlebotomies