Karolaine Colon Lebron
Toa Baja, ,PR
Summary
Dynamic healthcare leader with extensive experience at Pediatric University Hospital, excelling in utilization review and compliance auditing. Proven ability to enhance patient care planning and clinical documentation, while fostering interdisciplinary collaboration. Skilled in medical necessity assessment and conflict resolution, driving quality assurance initiatives to optimize service delivery and patient outcomes.
Overview
5
5
years of professional experience
Work History
Director of Utilization Review
Pediatric University Hospital
San Juan , PR
07.2023 - Current
- Administered fiscal operations for accounting, budget planning, authorizing expenditures and coordinating reporting.
- Kept informed of advances in medicine and computerized diagnostic and treatment equipment.
- Directed, supervised and evaluated medical, clerical or maintenance personnel.
- Managed appeals for denied services, providing additional information to support medical necessity.
- Maintained awareness of government regulations, health insurance changes and financing options.
- Contacted insurance carriers to obtain authorizations for services delivered to patients.
- Conducted comprehensive reviews of patient records to ensure medical necessity and compliance with healthcare standards.
- Evaluated proposed treatments or services based on appropriateness, necessity, clinical efficacy, cost-effectiveness, and medical necessity guidelines.
- Provided feedback to healthcare providers on clinical documentation improvement to support utilization review.
- Participated in interdisciplinary meetings involving case management, social work, physicians, nurses, and other members of the health care team.
- Educated healthcare providers on utilization review processes, criteria, and best practices.
- Provided guidance on compliance issues related to utilization review regulations.
- Maintained records management system to process personnel information and produce reports.
Cordinator of Utilitation Manegement and Disharge
University Hospital Of Puerto Rico
San Juan , PR
08.2022 - 07.2023
- Researched and analyzed community needs to determine program directions and goals.
- Cooperated with local service providers, outreach workers, case managers and collaborative agencies to facilitate services for members.
- Defined and applied utilization review methods to guarantee conformance with medical coverage plans.
- Developed and implemented case management plans for clients according to individual needs.
- Maintained detailed records of all interactions with clients in accordance with HIPAA regulations.
- Planned and directed nursing services in high-specialized patient care areas in accordance with state and federal guidelines.
- Evaluated the effectiveness of care plans and made changes as necessary based on client feedback.
- Assessed and identified service delivery challenges and opportunities within local area.
- Performed audits of objectives and case progression for case management team.
ER Registered Nurse
Provider Network Solutions
San Juan , PR
04.2021 - 05.2022
- Collaborated with public safety and community organizations to improve emergency response and patient outcomes.
- Achieved departmental goals and objectives by instituting new processes and standards for in-patient care.
- Treated patients by administering various types of medications and therapies.
- Participated in quality assurance activities to ensure that established standards of care were being met.
- Led debriefing sessions following major incidents, contributing to an environment of continuous learning and improvement.
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
- Responded quickly to codes and coordinated efficient and skilled care.
- Observed strict safety measures, including checking medication dosages before administration to patients.
- Provided emotional support to family members during traumatic events in the ER setting.
- Contributed to clinical research projects related to ER nursing practice.
Registered Nurse
Hospital Wilma N Vázquez
Vega Baja, PR
03.2020 - 03.2021
- Demonstrated ability to work independently as well as collaboratively within a team environment.
- Responded to emergency situations with speed, expertise and level-headed approaches to provide optimal care, support and life-saving interventions.
- Counseled patients and caregivers, providing emotional, psychological and spiritual support.
- Conducted health assessments and developed patient care plans as needed.
- Collaborated with multidisciplinary team members to develop individualized plans of care for each patient.
- Performed wound dressing changes, administered IV medications, and monitored vital signs.
- Successfully managed multiple tasks while maintaining focus on providing safe, high-quality patient care.
- Trained new nursing staff and students, sharing knowledge and best practices in critical care nursing.
- Detected emerging problems by monitoring patients' behavior, vital signs and fluid intake and output.
- Supervised cardiac monitors, mechanical ventilators and alarms and oxygen delivery devices.
Education
Bachelor of Science - Nursing
Universidad Metropolitana Bayamon
Baramon, PR07-2018
Skills
- Medical necessity assessment
- Utilization review
- Healthcare regulations
- Interdisciplinary collaboration
- Patient care planning
- Clinical documentation
- Quality assurance
- Staff supervision
- Compliance auditing
- Conflict resolution
- Effective communication
- Data collection
- Licensed RN
- Infection control measures
- EMR / EHR
- Case management
- Emergency procedures
- Regulatory compliance
- Clinical judgment
- Intake and discharge
- OR and ER experience
- IV drug therapy management
- Patient monitoring
- Pediatric nursing
- Data analysis
Timeline
Director of Utilization Review
Pediatric University Hospital
07.2023 - Current
Cordinator of Utilitation Manegement and Disharge
University Hospital Of Puerto Rico
08.2022 - 07.2023
ER Registered Nurse
Provider Network Solutions
04.2021 - 05.2022
Registered Nurse
Hospital Wilma N Vázquez
03.2020 - 03.2021
Bachelor of Science - Nursing
Universidad Metropolitana Bayamon