Jose Martinez RN BSN CHCQM
Miami,FL
Summary
Experienced Registered Nurse and healthcare quality professional with over 28 years across multiple clinical settings, including management in acute rehabilitation, medical surgical, ortho-spine, ICU, neurology, transplant and oncology units. Skilled in multiple EHR/EMR platforms such as Cerner, Epic, Availity, CarePort, Midas and knowledgeable in Medicare Advantage, Medicaid, and commercial insurance plans. Expertise in utilization management, InterQual / MCG guidelines, and post-acute care criteria and levels of care such as LTAC, acute rehabilitation, skilled nursing facilities, home health, hospice / palliative care and out patient. Bilingual in Spanish.
Overview
1
1
Certification
35
35
years of professional experience
Work History
Care Manager RN Field
Aetna Healthcare, Jackson Memorial Hospital
Miami, FL
10.2025 - Current
- Complete onsite member engagement visits for various population groups and target diagnoses including CHF, COPD, ESRD, DM, HemOnc, transplant, and neurology across Aetna service lines.
- Educate patients on disease pathophysiology, management, medications, and treatment plans to members using evidence-based tools and assessments with a goal to improve patient's understanding and adherence.
- Collaborate with hospital physicians, case managers, and social workers to support discharge planning process, provide patient benefits and coverage, and expedite post-acute authorizations with a goal to facilitate timely care transitions and avoiding unnecessary, length of stay.
- Review member-specific care needs by identifying SDOH and barriers, with the goal of reducing gaps in care, and reinforce education to support treatment adherence.
- Identify post-acute needs, submit appropriate referrals to Aetna telephonic care managers and care partners, and assist patients in scheduling primary care or specialty visits to improve access to care and reduce readmission risk.
- Track member progress, share updates, make care-plan recommendations, adjust approaches as needed to care team and stakeholders and provide progress and tracking reports to stakeholders.
Case Manager, Ortho-Spine Unit
HCA Mercy Hospital
Miami, FL
11.2024 - 05.2025
- Perform initial assessments/ discharge planning entry (DPE) within twenty-four hours of newly admitted patients and proactively identify any needs / barriers for discharge.
- Complete initial clinical reviews on all admitted status patients and concurrent reviews utilizing InterQual.
- Provide patient/family education on post-acute levels of care, initiate appropriate post-acute care referrals with follow up on providers' acceptance, obtain patient choice letters, complete SNF transfer forms, PASSR and other pertinent documents to ensure safe transition.
- Educate patient/family on the appeals process, assisting with the initiation of an appeal, obtaining an appeal reference number and creating pertinent clinical file for submission to the appeal entity.
- Conducted daily multidisciplinary rounds to document qualifying stay input from attending MD and RN.
- Tracked and documented re-admission cases and avoidable days, providing weekly reports on cases exceeding the 10-day length of stay.
Manager of acute rehab admissions, Acute Rehab Unit
Jackson North Medical Center
Miami, FL
02.2017 - 10.2024
- Reviewed referred internal / external referrals currently in acute care settings including ICU, CCU, medical-surgical, neuro step-down, ortho-spine, and oncology units including outside medical records from other acute hospitals, physician offices, and onsite home evaluations.
- Established and adhered with CMS criteria by assessing / completed pre-admission screens covering current diagnosis, active problems, medical necessity, comorbidities, prior level of function, discharge plan to home versus ALF, and current rehab modalities for physiatrist signature.
- Initiated and directed prior-authorization requests with Medicare Advantage, Medicaid HMO, and commercial payers; negotiated rates with workers' compensation and coordinated peer-to-peer discussions between attending physicians and insurance medical directors.
- Collaborated with attending physician, case management and social service teams during multidisciplinary rounds, offering input on appropriate patients based on established best practice and CSM criteria.
- Managed acute rehabilitation admissions process and responsible for training new staff on CMS-13 diagnosis guidelines / medical necessity criteria to support accurate processing of post-acute care patient needs.
- Helped develop and launch remote andmissions program during 2020 pandemic, improving capacity to admit and created process for weekend referral reviews ad admissions.
Clinical Nurse Liaison, Villa Maria/St. Catherine's East
Catholic Health Services
Miami, FL
04.2001 - 12.2016
- Reviewed referred candidates promptly in acute care settings, including ICU, CCU, medical, surgical, neuro step-down, ortho-spine, oncology, and obtained outside records from acute hospitals, physician offices, and onsite home evaluations.
- Documented findings in preadmission screens, including current diagnosis, active problems, medical necessity, comorbidities, prior level of function, discharge plan home vs ALF, and current rehab modalities for physiatrist signature.
- Provided guidance across Catholic Health Services post-acute care lines, including acute rehabilitation hospitals, sub-acute units, assisted living facilities, home health care, HUD residences, and Catholic Hospice.
- Built professional relationships with private practices, hospital-based physicians, and community referral sources to support stable patient census.
- Educated patients and families on service line options, set clear expectations, and encouraged questions to improve understanding of post-acute care.
- Scheduled and led educational in-services in different settings on new or updated service lines for target audiences to include physicians, hospital clinical staff, and community audiences to increase service line awareness and collaboration.
Precertification Nurse Liaison
Florida Acute Care Specialists
Coral Gables, FL
01.2000 - 03.2001
- Reviewed precertification cases and approved medically appropriate authorizations for elective procedures, emergency room visits, and observation-to-inpatient status changes for assigned Medicare Advantage members.
- Applied Milliman and Robertson criteria to set inpatient length of stay for invasive and surgical cases, and completed concurrent reviews with InterQual for care alignment.
- Supported timely action on catastrophic admissions and denied cases, and issued avoidable days to improve resource use.
Hospice Nurse Liaison
Hospice Care of Miami-Dade County
Miami, FL
11.1997 - 12.1999
- Supported launch of new hospice program in Miami-Dade County by securing certificate of need, finding office space, and helping recruit interdisciplinary staff and medical director.
- Set up ancillary service contracts for inpatient care through area hospitals, skilled nursing units, home delivery pharmacy, durable medical equipment providers, and continuous care nursing agency.
- Delivered community in-services to introduce new product line and connect with physician offices, assisted living facilities, skilled nursing units, hospital social workers, and community ancillary services.
Staff LPN, Oncology unit
Baptist Hospital
Miami, FL
11.1991 - 11.1997
- Delivered comprehensive patient care for admitted oncology unit patients in partnership with assigned RN.
- Educated patients and families on discharge instructions, ensuring understanding of critical information.
- Contributed to discharge planning rounds, reporting on patient needs and identifying potential barriers.
Education
Bachelor of Science - Nursing
Western Governor's University
Salt Lake City, UTAssociate of Science - Nursing
Excelsior College
Albany, NYSkills
- Case management
- Care coordination
- Discharge planning
- Utilization management
- Utilization review
- InterQual criteria
- Medicare authorization
- Clinical assessment
- Transitional care
- Care planning
- Outcome assessment
- Case assessments
- Care supervision
- Patient care coordination
- Staff training
- Critical thinking
- Care program management
Certification
Multistate Registered Nurse, State of Florida Department of Health, License Number RN 9362401 expiration date April 2027., Certified in Health Care Quality and Management, American Board of Quality Assurance and Utilization Review Physicians, ID# 130736, expiration September 30, 2027.
Timeline
Care Manager RN Field
Aetna Healthcare, Jackson Memorial Hospital
10.2025 - Current
Case Manager, Ortho-Spine Unit
HCA Mercy Hospital
11.2024 - 05.2025
Manager of acute rehab admissions, Acute Rehab Unit
Jackson North Medical Center
02.2017 - 10.2024
Clinical Nurse Liaison, Villa Maria/St. Catherine's East
Catholic Health Services
04.2001 - 12.2016
Precertification Nurse Liaison
Florida Acute Care Specialists
01.2000 - 03.2001
Hospice Nurse Liaison
Hospice Care of Miami-Dade County
11.1997 - 12.1999
Staff LPN, Oncology unit
Baptist Hospital
11.1991 - 11.1997
Bachelor of Science - Nursing
Western Governor's University
Associate of Science - Nursing
Excelsior College