Kayla Gutierrez

• Manage clinical delegation relationships between the organization and external partners, ensuring compliance with contractual obligations and CMS regulatory requirements.
• Monitor and interpret policy updates, adjusting internal workflows and documentation processes to align with evolving standards.
• Prepare and present detailed reports and case summaries to delegate organizations, highlighting completed clinical reviews and outcomes for their patient populations.
• Serve as a primary point of contact for delegated entities, responding to information requests and facilitating clear, timely communication.
• Develop and maintain comprehensive case files, ensuring accuracy, completeness, and readiness for audits or regulatory review.
• Collaborate with internal departments to ensure delegated processes are executed efficiently and in accordance with quality standards.
• Support audit readiness by maintaining documentation and tracking performance metrics related to delegated clinical review activities.

• Supported utilization management initiatives by developing streamlined forms and protocols for prior authorization processes.
• Became a member of a specialized review team that encompassed all review types, markets, and payors.
• Reviewed medical records to assess the medical necessity and appropriateness of requested services.
• Investigated complex cases requiring additional clinical information before making coverage determinations.
• Delivered educational materials and presentations to internal teams and external partners on authorization and policy updates.
• Communicated with provider offices regarding pending authorizations and regulatory changes.
• Analyzed clinical documentation (e.g., progress notes, labs, imaging) to ensure accurate coding and compliance.
• Participated in training sessions and meetings on CMS and payer policy updates.
• Interpreted benefit plans, medical necessity criteria, and policy language to ensure appropriate service utilization.
• Developed process improvement strategies to enhance efficiency and compliance in prior authorization workflows.
• Utilized RPMS and EHR systems for documentation and case management.
• Ensured compliance with HIPAA and CMS regulatory standards.
• Maintained up-to-date knowledge of ICD-10, CPT, HCPCS, DRG assignment, and Medicare billing requirements.

Worked as travel nurse in this role. Continued in my specialty of PCU as in my previous role at Advent Health Wesley Chapel

Worked as travel nurse in this role. Continued in my specialty of PCU as in my previous role at Advent Health Wesley Chapel

• Delivered direct patient care, including medication administration, monitoring, and care coordination.
• Assessed and managed patients with complex conditions such as heart failure, renal disease, and pulmonary issues.
• Collaborated with physicians and interdisciplinary teams to develop and implement care plans.
• Interpreted EKG/telemetry readings and responded to changes in patient acuity.
• Provided palliative care and patient education to support care transitions and improve outcomes.
• Maintained compliance with HIPAA, Joint Commission standards, and CMS guidelines.
• Utilized EMR systems for documentation, order entry, and care coordination.
• Mentored and trained new nursing staff on clinical protocols and best practices.
• Managed central lines, PICC lines, and Medi-ports with a focus on safety and infection control

• Supported patient care by assisting with mobility, daily living activities, and personal care needs.
• Maintained accurate medical records and reported changes in patient conditions.
• Collaborated with nursing staff to ensure safe, efficient, and compassionate care.
• Collected lab specimens and adhered to safety protocols.
• Communicated effectively with patients, families, and interdisciplinary teams.
• Advocated for patient needs and contributed to high-acuity care through team-based nursing.