Kayla Santa Ana
HMSA
Lihue
10
years of professional experience
Detailed-oriented Registered Nurse with over 13 years of clinical experience in medical management, case management, and care coordination. Expertise in reviewing medical necessity, applying clinical guidelines, and coordinating interdisciplinary care. Committed to ensuring regulatory compliance and delivering cost-effective healthcare outcomes.
Work History
Nurse Reviewer - Clinical Review Unit
1 Year 5 Months- Review clinical documentation for pre-certification reviews of inpatient and outpatient services and post-service reviews of suspended claims, by applying clinical expertise against plan benefits, medical policies, and nationally-accepted clinical guidelines.
- Applies appropriate medical necessity criteria from established medical policies and clinical practice guidelines.
- Refer members to Case Management programs to ensure continuity of care.
- Collaborate with healthcare providers, case managers, and Medical Directors to facilitate authorization decisions.
- Document clear, accurate clinical rationales within required turnaround times to support decision-making.
Health Coordinator
5 Years 2 Months- Conducted face-to-face Health and Functional Assessments (HFA) and developed Health Action Plans for Quest Integration and DSNP Adult members in the Long-Term Services and Support (LTSS) program in a field based setting.
- Identified and initiated referrals for social service programs, enhancing access to financial, psychosocial, community, and state supportive services.
- Collaborated with healthcare providers to coordinate patient care, improving adherence to treatment plans and overall health outcomes.
Service Coordinator
3 Years 8 Months- Conducted face-to-face Health and Functional Assessments (HFA) and developed Individualized Services Plans for Quest Integration and Medicare Adult/Child members in the Special Health Care Needs (SHCN) program, At Risk program, and Long-Term Services and Support (LTSS) program in a field-based setting.
- Identified and initiated community supportive services to enhance member access to essential resources.
- Developed and maintained strong relationships with members, ensuring tailored support based on their service needs.
Education
Bachelor of Science - Nursing
Associate of Science - Nursing
Certificate of Achievement - Practical Nursing
Skills
Clinical Documentation Review
Medical Necessity Determination
Prior Authorization Review
Medicare and Medicaid knowledge
Commercial Health Plan Knowledge
Critical Thinking
Time Management
Strong Clinical Judgment
Multitasking
Communication
License
State of Hawaii Registered Nurse License (RN # 73191) expires June 2027
Timeline
Nurse Reviewer - Clinical Review Unit
HMSA
03.2025 - CurrentRead More
Health Coordinator
HMSA
01.2020 - 03.2025Read More
Service Coordinator
AlohaCare
05.2016 - 01.2020Read More
University of Hawaii At Manoa
Bachelor of Science from Nursing
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Kauai Community College
Associate of Science from Nursing
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Kauai Community College
Certificate of Achievement from Practical Nursing
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