Kenneth Christian Alagon

• Complete and oversee MDS assessments in accordance with CMS, Medicare, Medicaid, and state regulations

• Ensure timely and accurate submissions to maximize reimbursement and maintain compliance

• Support facilities with care area assessments (CAAs), care planning, and interdisciplinary coordination

• Provide education and guidance to facility staff related to MDS processes and best practices

• Assist with audits, surveys, and corrective action plans related to MDS and PDPM

• Collaborate with DONs, Administrators, and Regional Clinical teams

• Travel to assigned facilities within the Baltimore and surrounding Maryland markets as needed

Provided specialized care in Skilled/Rehab unit, utilizing critical thinking and problem-solving skills to support patients transitioning from acute hospital care to independent living.

• Documents all activities in the appropriate system(s) on a timely basis
• Reviews individual medical cases to confirm that they are getting the most appropriate care
• Weighs the patient's situation against the policy held by the patient, the standards of the insurance company, and the costs which may be involved in treatment
• Promote the quality and cost effectiveness of medical care by applying clinical knowledge and the appropriate application of policies and guidelines to prior authorization requests
• Ensures that prior authorization requests are completed in a timely fashion to meet contractual requirements and that all reviews are conducted using nationally recognized and evidence-based standards
• Evaluates the pre-service authorization request received for scheduled inpatient admissions, ambulatory surgeries, and outpatient services and out of network providers
• Determines the appropriate level of care for patient stays in acute care facilities in compliance with acute care guidelines; prior authorization medical necessity review, including determination of appropriate provision of observation care, outpatient or inpatient rehabilitation services, DME, Home Health and other ancillary healthcare services in compliance with approved care guidelines
• Acute hospital pre-admission / Skilled Nursing Facility / Hospice and other Long Term Care facilities
• Surgical / Diagnostic procedures / Therapies / Durable Medical Equipment and Home Care
• Determines utilization decisions based upon nationally recognized and evidence-based guidelines
• Reviews prior authorization requests with Medical Directors as directed
• Transfer calls to Cigna, pertaining to Cigna's products and services other than medical. Nurses may be engaged to support the centralized fax administration process to complete necessary research and document production to send an outgoing fax to resolve an inbound inquiry to the customer's satisfaction
• Provides review of requests for outpatient and/or inpatient clinical services
• Manages the provision of cost containment services by determining the medical necessity and appropriateness of setting and treatment, and steerage to network health care professionals
• Review cases for potential need for case management Premium Solutions products and makes referrals
• Provides service delivery on assigned products in a manner consistent with established standard policies/procedures and customer result expectations
• Authenticate both the Customer and the Health Care Professional's Information by means of validating the clinical information received in Providerlink should match on what is listed on the system
• Capture all relevant clinical information given
• Make a valid and accurate decision based on hierarchy of guidelines and properly document it in the client's system
• Communicate the decision to providers while observing internal turnaround time periods and special turnaround times based on federal/state mandates
• Protect and secure members' Protected Health Information (PHI)
• Utilize existing resources to provide resolution to healthcare professional's concern

Case Review & Analysis:

• Analyze denied claims, medical documentation, and clinical records to determine medical necessity.
• Construct detailed clinical arguments and submit appeal letters to insurance carriers.
• Utilize knowledge of InterQual, MCG, and ICD-10/CPT codes to support appeals.
• Regulatory Compliance
• Ensure all appeals meet regulatory and accreditation standards.
• Communicate with providers, payers, and internal teams to resolve disputes.

• - Care of emergent and non-emergent patients
• - Head-to-toe assessments - knowledge of normal vs. abnormal findings and reporting of abnormal findings to Charge Nurse, M.D., if warranted
• - Critical thinking to intervene with appropriate intervention for urgent/emergent care. Care of the acute and chronically ill patients
• - Identifying and managing life-sustaining physiologic functions in unstable patients
• - Ensure the provision of quality medical care to patients requiring emergency treatment in accordance with physician orders, hospital policy, and standard nursing practices.
• - Basic IV and central line skills
• - Knowledge of hemodynamics

• ER nurses assist in the admission/consultation of the patient. Every patient has a unique set of admission/consultation policies and procedures.
  • - Interviews the patient/relatives on pertinent data necessary for consultation or admission.
  • - Directs and coordinates members of the patient care team, focusing on the provision of individualized quality patient care.
  • Monitored patient vital signs continuously during emergency interventions, ensuring timely detection of complications and improving overall patient safety.
  • Assessed incoming patients rapidly to prioritize care needs, accelerating treatment delivery and improving emergency department throughput.
  • Delivered wound care and administered emergency medications promptly, enhancing patient comfort and reducing complications during critical treatment phases.