Lourdes Amaya

I work in the precert prior authorizations UM department. We Process referrals authorizations for offices, hospitals, home health agencies as well as therapy agencies. Gather clinical information regarding cases/faxes have to make sure HCPS (CPT Codes), ICD 10 (Diagnosis codes), servicing and ordering providers NPI# and all information are listed on all referrals and or authorization forms. Knowledge of Managed Healthcare and Medicaid. Responsible for providing non-clinical support to Utilization medical management operations(UM), which includes handling more complex file reviews and inquiries from members and providers. We then determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). Conduct initial review of files to determine appropriate action required. Maintain and update tracking databases. Prepare reports and document all actions. Respond to requests, calls or correspondence within scope. Provide general program information to members and providers as requested. Review and assist with cases. Act as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. Collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager. Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. In this role we are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
My job is to also assist in processing Web authorizations know as Internet Clinical Review (ICR) for providers. I also helped directly with our Medical Directors to send out Medical Determinations faxes for approvals, partial approvals or denials for services being requested for our members to providers. As well as assist to translate letters from English to Spanish using Spark(AI program).I work in the precert prior authorizations UM department. We Process referrals authorizations for offices, hospitals, home health agencies as well as therapy agencies. Gather clinical information regarding cases/faxes have to make sure HCPS (CPT Codes), ICD 10 (Diagnosis codes), servicing and ordering providers NPI# and all information are listed on all referrals and or authorization forms. Knowledge of Managed Healthcare and Medicaid. Responsible for providing non-clinical support to Utilization medical management operations(UM), which includes handling more complex file reviews and inquiries from members and providers. We then determines appropriate area to refer or assign case (utilization management, case management, QI, Med Review). Conduct initial review of files to determine appropriate action required. Maintain and update tracking databases. Prepare reports and document all actions. Respond to requests, calls or correspondence within scope. Provide general program information to members and providers as requested. Review and assist with cases. Act as liaison between medical management operations and other internal departments to support ease of administration of medical benefits. Collaborate with external community-based organizations to facilitate and coordinate care under the direction of an RN Case Manager. Responsibilities exclude conducting any utilization management review activities which require interpretation of clinical information. In this role we are expected to have strong oral, written and interpersonal communication skills, problem-solving skills, facilitation skills, and analytical skills.
My job is to also assist in processing Web authorizations know as Internet Clinical Review (ICR) for providers. I also helped directly with our Medical Directors to send out Medical Determinations faxes for approvals, partial approvals or denials for services being requested for our members to providers. As well as assist to translate letters from English to Spanish using Spark(AI program).

• Coordinated workshops and events, fostering collaboration among diverse organizations and participants.
• Facilitated strong relationships with community members by attending local events, serving as a liaison between the organization and its constituents.
• Conducted needs assessments to identify gaps in services and inform program development initiatives.
• Cultivated partnerships with local businesses, schools, and nonprofits to expand outreach efforts.
• Collaborated with community members to develop and implement service initiatives.
• Participated in community events to promote services and engage with public.
• Referred clients to appropriate team members, community agencies and organizations to meet treatment needs.
• Conduct phone calls and home visits to reach out to adult, children and pregnant women Medicaid recipients.

• Designed and implemented engaging lesson plans to enhance student learning and participation.
• Developed individualized education plans to address diverse learning needs of students.
• Integrated technology into classroom activities to improve student engagement and resource accessibility.
• Collaborated with colleagues to refine curriculum and ensure alignment with educational standards.
• Analyzed student performance data to identify areas for improvement and drive instructional changes.
• Established positive relationships with parents and community members to foster collaborative education efforts.
• Developed strong relationships with students, parents, and colleagues by maintaining open lines of communication and fostering a supportive learning environment.
• Enhanced classroom engagement through the use of interactive teaching methods, such as group projects and hands-on activities.
• Managed classroom behavior effectively by establishing clear expectations, modeling appropriate conduct, and consistently enforcing established rules and consequences.
• Identified struggling students early on and provided additional support through tutoring sessions and modified lesson plans.
• Modified lessons and curriculum to accommodate diverse learners by using strategies such as peer-assisted learning and group work.
• Met with students, parents and administrators to address and resolve students' behavioral and academic issues.
• Developed and implemented classroom routines to address varying student needs.
• Worked with staff members and teachers to design comprehensive and individualized plans to optimize student education.
• Scheduled conferences with parents to discuss students' progress and classroom behavior.
• Boosted cultural awareness by incorporating children's literature from world cultures.

• Supported diverse student needs through individualized tutoring and classroom activities
• Assisted lead teacher in developing engaging lesson plans and instructional materials
• Facilitated communication between students, teachers, and parents to enhance learning outcomes
• Implemented classroom management strategies to create a positive learning environment
• Organized educational resources and materials for effective lesson delivery
• Managed classroom behavior effectively, maintaining a focused and respectful atmosphere conducive to learning.
• Facilitated small group discussions that encouraged critical thinking and collaborative problem-solving among students.
• Participated actively in staff meetings, contributing ideas for enhancing existing teaching methods.
• Provided one-on-one tutoring sessions for struggling students, leading to significant improvements in their language skills.
• Implemented assessment tools to monitor student progress, identifying areas of improvement and adjusting instructional strategies accordingly.
• Enhanced language proficiency by implementing interactive games and activities in daily lessons.
• Contributed to ongoing professional development initiatives by attending workshops, conferences, and training programs related to ESL education.
• Maintained accurate records of student attendance, assessments results, and overall performance.
• Assisted lead teacher in optimizing curriculum content for enhanced ESL learning outcomes.
• Coordinated closely with other educators within the school community, facilitating interdisciplinary connections between subjects.
• Communicated regularly with parents regarding student progress, addressing concerns and providing resources for at-home support as needed.
• Mentored and tutored individual students needing additional help.
• Monitored student behavior in classes, laboratories and on field trips for unsafe or rule-breaking concerns.