Summary
Overview
Work History
Education
Skills
Other Jobs
References
Languages
Timeline
Generic

Rose Macias

Harlingen,Texas

Summary

Stepping into the role of Care Delivery Advisor at GDIT, the opportunity to support Federal contracts and quality measurement and reporting programs, specifically focusing on the Centers for Medicare and Medicaid Services (CMS), is embraced eagerly. With a keen eye for detail and a commitment to excellence, expertise will be utilized to ensure the successful implementation, monitoring, and evaluation of payment models. Providing invaluable guidance on care delivery approaches within CMS' innovative payment models, dedication to driving improvements in the quality of care is unwavering. At GDIT, poised to chart a path of professional growth and make a lasting impact on challenging projects in a supportive and empowering environment.

Overview

28
28
years of professional experience

Work History

Star Plus Waiver RN Case Manager

Molina Healthcare
01.2022 - Current
  • Provided emotional support to patients coping with chronic illness or end-of-life decisions, fostering resilience during difficult times.
  • Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
  • Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
  • Educated patients and families on available community resources, facilitating access to necessary support services.
  • Completed face-to-face comprehensive assessments of members per regulated timelines.
  • Facilitated comprehensive waiver enrollment and disenrollment processes.
  • Reduced hospital readmission rates through effective case management and patient education on self-care techniques.
  • Served as a key liaison between patients, families, and healthcare providers, fostering open communication and trust among all parties involved in the care process.
  • Developed and implemented case management plans, including a waiver service plan, in collaboration with the member, caregiver, physician and/or other appropriate healthcare professionals and member's support network to address the member needs and goals.
  • Performed and monitored ongoing care plans to evaluate effectiveness, documented interventions and goal achievement, and suggested changes accordingly.
  • Promoted integration of services for members including behavioral health care and long term services and supports, home and community to enhance the continuity of care for Molina members.
  • Assess for medical necessity and authorize all appropriate waiver services.
  • Evaluated covered benefits and advise appropriately regarding funding source.
  • Conducted face-to-face or home visits as required.
  • Facilitated interdisciplinary care team meetings for approval or denial of services and informal ICT collaboration.
  • Used motivational interviewing and Molina clinical guideposts to educate, support and motivate change during member contacts.
  • Assessed for barriers to care, provides care coordination and assistance to member to address psycho/social, financial, and medical obstacles concerns.
  • Identified critical incidents and develops prevention plans to assure member's health and welfare.
  • Provided consultation, recommendations and education as appropriate to non-RN case managers
  • Worked cases with members who have complex medical conditions and medication regimens
  • Conducted medication reconciliation when needed.
  • Advocated for patients'' rights and preferences, working diligently to align care with individual values and goals.
  • Optimized resource utilization by identifying opportunities for cost containment while maintaining quality of care.
  • Navigated regulatory requirements effectively, ensuring proper documentation and compliance with relevant laws and guidelines.
  • Assisted in the development of policies and procedures that improved the efficiency of case management processes within the organization.
  • Educated family members and caregivers on patient care instructions.
  • Used first-hand knowledge and clinical expertise to advocate for patients under care and enacted prescribed treatment strategies.
  • Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
  • Conducted several fully comprehensive in-person MNLOC assessments and transmitted to the portal to be then submitted to TMHP

RN Case Manager/Service Coordinator Star Plus Waiver

Cigna Health Spring
05.2015 - 12.2021
  • I work with members, member's family, and providers to develop and actuate a fully comprehensive individualized service plan
  • Conducted several fully comprehensive in-person MNLOC assessments and transmitted to the portal to be then submitted to TMHP
  • Conducted health risk and other member assessments
  • Used clinical judgment to identify physical and behavioral health needs and worked with the member and caregiver to establish an appropriate plan of care and services that minimize needs based on medical necessity criteria and benefit guidance
  • Worked with member to close clinical and pharmacy gaps and to mitigate non-clinical barriers to care
  • Acted as a liaison and facilitates the coordination of benefits, resources, healthcare providers, and institutions
  • Completed and filed all assessments and implemented the care plans
  • Maintained a maximum weekly face to face visit schedule of seven members on average and at times exceeded that quota, average caseload of 125 members
  • RUG certified and competent to handle members ISP, and account
  • Completed and attended all necessary trainings new changes implemented by the state or internally
  • Performed and participated in IDT meetings with DAHS, and Pas Agencies in member situations or concerns
  • I am a team player and work and communicate closely with my service coordinators and provide pep talks when needed to motivate them and to assist them spiritually
  • Trained new Sc's on face to face one on one session and explained in detail all the duties of the Service Coordinator including assessments, forms, time-frames, adaptive aids, and explaining the benefits of Star Plus Waiver and what how each service needs to meet criteria and guidelines
  • Have taken new SC's on visits with me to show them how detailed I am when seeing a member and explained to see the member holistically and to properly assist them the best we can with the resources they qualify for
  • Have explained to new Sc's the importance of outreach to community resources
  • Have explained and have been a strong advocate for our members
  • Have offered and always make myself available to assist Sc's still learning and answering questions with a motivated and positive tone and mindset
  • Have assisted many members with minor home modifications to their home that I identified to prevent further falls, hospitalizations and injury
  • I have been asked and assisted managers review items, and cases in the past due to my judgment and expertise
  • Have handled in great detailed protective supervision cases, respite cases, pas increases, transfers, upgrades, post hospitals, follow ups as well as reassessments
  • I am accountable of everything I do, and have a great memory and skill of recalling cases, members, and ensuring all work is completed well, and with integrity.
  • Provided emotional support to patients coping with chronic illness or end-of-life decisions, fostering resilience during difficult times.
  • Managed complex cases involving multiple comorbidities, requiring close monitoring and coordination of various healthcare services.
  • Collaborated closely with physicians to develop individualized treatment plans, supporting optimal patient outcomes.
  • Educated patients and families on available community resources, facilitating access to necessary support services.
  • Enhanced patient care by developing comprehensive care plans and coordinating with interdisciplinary healthcare teams.
  • Reduced hospital readmission rates through effective case management and patient education on self-care techniques.
  • Served as a key liaison between patients, families, and healthcare providers, fostering open communication and trust among all parties involved in the care process.
  • Coordinated care conferences with interdisciplinary team members, ensuring all perspectives were considered in the development of comprehensive treatment plans.
  • Optimized resource utilization by identifying opportunities for cost containment while maintaining quality of care.
  • Navigated regulatory requirements effectively, ensuring proper documentation and compliance with relevant laws and guidelines.
  • Assisted in the development of policies and procedures that improved the efficiency of case management processes within the organization.

Pediatric Private Duty Registered Nurse

All About Kids Home Health
05.2010 - 05.2015
  • Provided full head to toe assessments with every start of a shift and assessed the patient throughout my shift
  • Provide skilled nursing care in a pediatric patient's home on an hourly basis
  • Skillful observations were made on patients that health status changed rapidly
  • Provided medical treatments
  • Detailed charting
  • Medication management
  • Medication administration
  • Provided skilled Trach care and handling
  • Provided skilled G tube care and handling
  • Cared for patients that were Premature infants - premature infants (24 - 32 weeks) with chronic complications
  • Cared for respiratory compromised children -bronchopulmonary dysplasia, traumatic brain injury complications, syndrome- related complications, tracheostomy either permanent or temporary
  • Cared for Cardiac-compromised children - syndrome-related complications, congenital anomaly
  • Cared for Neurologically-compromised children - seizure disorder, syndrome-related, Cerebral Palsy, seizure control devices; Ventilator dependent children
  • Gastrostomy - children who require feeding either via NJ tube or G Button
  • Went on doctor appointments with patients and wrote new orders on med changes, and implemented changes and modifications to plan of cares
  • Worked closely with social workers on ensuring the patient is receiving all the essential equipment and devices needed to grow as a healthy and functioning child
  • Worked closely with Physical, Occupational, and Speech therapist to work on reaching certain goals with the patient
  • Provided a healthy, positive, motivating environment for the patient and family and gave a positive outlook on life
  • Had a strict hand washing policy and kept my working area clean at all times
  • Trained and oriented new nurses to work in the home health field
  • Received a Certificate of Appreciation(granted only to those awarded) in recognition of valuable services, and loyal contributions in order to achieve excellence and success(12-24-12).

Newborn ICU Registered Nurse

Valley Baptist Medical Center
06.2009 - 09.2010
  • Worked as skilled member on a nursing team in the Newborn Intensive Care Unit
  • Provided care to neonates and their families through assessment
  • Provided continuation or alteration of treatment and evaluation of care
  • Provided direct patient care for newborn babies
  • Analyzed and evaluated the effectiveness of care to mothers and babies
  • Interpreted clinical results and initiated investigations
  • Provided clinical support and training to staff and students
  • Ensured that accurate documentation and administrative records are up to date
  • Made sure equipment was clean and safe to use
  • Prepared nursing care plans
  • Educated parents how to maintain the patient's health at home
  • Created a welcoming, caring, and safe environment for neonates and their families
  • Worked responsibly and under own initiative
  • Had a calm disposition and able to think quickly
  • Able to assess neonate's physical, psychological and social problems
  • Acted as a role model for newly qualified nurses
  • Performed life sustaining care for patients
  • Administered medications orally, iv, uvc, uac, and via gtube
  • Monitored vital signs and provided vital nutrients to newborns
  • Ensured and assessed that infants were breathing properly and their lungs were growing and functioning properly as well
  • Worked with and assisted specialized and upper level nurses as well as physicians and assisted in treatment plans and examinations.

Agent/Quality Control/Training

Advance Call Center Tech
03.2002 - 01.2006
  • Full time Customer service agent for the Sears Balance transfer department
  • Helped detect and prevent fraud on Sears's accounts where balance transfers were in the process
  • Was promoted to a Sears Fraud Investigations analyst
  • Once fraud was detected I investigated the claim and was in contact with the authorities and based on the information found I either denied the claim or cleared off the account and reported it to the credit bureau as fraud
  • Developed Excellence in the Fraud Investigation training course
  • This job included a lot of paper work, faxing, filing and excellent knowledge of all computer systems used for this department
  • Demonstrated proper phone etiquette and multi-tasking
  • Within 6 months was promoted to the quality department as a quality coach
  • Once in the quality department I listened and graded live calls for the Sears fraud Investigation Department
  • Once these calls were monitored and graded they were distributed to the department's supervisor and then they were issued out to each agent by me face to face to explain the grade and reason and areas needed for improvement or praise for a job well done
  • All scores were entered into a database and on excel spreadsheets to continually monitor the improvement of the overall department I was grading and these reports were used to provide the managers input for recommendations of bonuses and/or possible write ups
  • Coaching Sessions were done to provide feedback to each agent and answer any questions they might have on the spot to ensure the rational was given for the grade received and educated to explain the correct way the call and account should have been handled
  • Trained all new employee's coming to the department, which included one on one training
  • Organized materials for various training sessions, and prepared and reserved the training room and organized computers and log-on ids for each new employee
  • Trained and graded each new employee and evaluated the competency of the employee and either approved for them to continue on the floor to work live on calls, or suggested more training or possibly not someone that is recommended to be part of this program/department and submit test grades, and my evaluation to HR to show this
  • Became quality coach for a new program A.C.T was contacted with for the Sears Collections department
  • Became ACA Certified as a Debt Collector
  • Trained a class of 25 to enter the floor as knowledgeable collectors
  • Changed to grading and monitoring calls for Dell Financial Services and for Litton Mortgage Company coming out of Johnson, Tennessee
  • I had minimal supervision, provided e-mail reports of all grades, trainings and scores completed
  • Kept an up to date spreadsheet of the monitoring's done including team and individual grades
  • Received a certificate of Completion for supervisor and Payroll Training.

Sales Associate/ Assistant Manager

Ann Taylor
02.2000 - 03.2003
  • Supervised, and managed and trained a 15-person sales staff
  • Extensively interviewed sales people to insure we always hired the best selling team
  • Expanded clientele where high dollar clients became loyal to the Ann Taylor products and preferred my service
  • Helped increase store size by selling in the million-dollar range within a year and by becoming a level one store
  • Prepared meetings and corresponded with member representatives on upcoming meetings
  • In charge of the loss preventive section of the store
  • Did an inventory count on a daily basis and was reported
  • Once a year helped process the inventory for the entire store
  • Issued schedule reports and helped allocate hours worked for the employees time on our payroll system
  • Processed UPS shipments and signed for incoming shipments.
  • Boosted customer satisfaction levels through exceptional service, addressing concerns promptly, and providing a welcoming store environment.
  • Increased sales revenue by building strong rapport with customers and recommending appropriate products based on their needs.
  • Achieved monthly sales targets consistently by implementing effective sales strategies and maintaining a high level of product knowledge.
  • Managed conflict resolution with dissatisfied customers professionally, resulting in improved customer retention rates.
  • Generated new sales leads to achieve and exceed monthly sales goals.
  • Maximized profitability with strategic upselling techniques during one-on-one interactions with clients at the point of purchase.
  • Conducted regular competitor analysis to stay informed about market trends, adjusting pricing strategies accordingly for optimal results.
  • Managed efficient cash register operations.
  • Built customer loyalty and retention by delivering excellent shopping experiences.
  • Organized racks and shelves to maintain store visual appeal, engage customers, and promote specific merchandise.
  • Handled cash transactions efficiently while adhering to company cash handling policies, ensuring accuracy in all financial exchanges.

Selling Specialist

Foley's (Men's Dept.)
01.1999 - 02.2000
  • Provided excellent customer service
  • Executed big floor moves for the department in order to represent new product lines and increase sales
  • Was the only selling specialist in charge of handling 3 departments at the same time {Guess, Calvin Klein, Polo Jeans, and Nautica Jeans}
  • Had minimal supervision and increased revenue sales by 25%, which helped me achieve monthly quotas and receive bonuses.

Sales Associate/Assistant Manager/Key holder(Team Lead appointed by Manager)

Sears Roebuck (Men's Dept.)
03.1996 - 06.1998
  • Was very skillful at handling the cash register
  • Offered excellent customer service on a daily basis
  • Suggested new ideas that increased sales by 23%
  • Was very knowledgeable about the products sold
  • Assisted in managing a department of 20 employees with a full time schedule while attending high school
  • Had the authorization and approval of holding on to the department key to open and approve sales, returns, and any situation where manager key needed to be inserted
  • This was given to me when I was team lead by my manager
  • Attended manager meetings
  • Assisted in training new associates along with HR
  • As Key holder, was in charge during my key holder shift to ensure all 7 registers we had balanced and if they didn't had to calculate in a quick manner to report why there was not a balance and where it occurred and report to the main office.
  • Managed and motivated employees to be productive and engaged in work.
  • Accomplished multiple tasks within established timeframes.
  • Resolved staff member conflicts, actively listening to concerns and finding appropriate middle ground.
  • Monitored and analyzed business performance to identify areas of improvement and make necessary adjustments.

Education

Associate Degree of Applied Science in Nursing -

University of Texas at Brownsville and Texas Southmost College
Brownsville, TX
05.2009

Nursing

Texas State Technical College
Harlingen, TX

Tomball College
Tomball, Texas

Indiana University Northwest
Gary, Indiana

High School Diploma -

Merrillville High School
Merrillville, Indiana
06.1998

Skills

  • Chronic Disease Management
  • Discharge Planning
  • HIPAA Compliance
  • Multidisciplinary Approach
  • Care Coordination
  • Home care management
  • Utilization review
  • Case Evaluation
  • Clinical assessment
  • Community Resources
  • Medication Management
  • Quality Improvement
  • Healthcare regulations
  • Case Management
  • Medication monitoring
  • Regulatory Compliance
  • Policy Adherence
  • Interdisciplinary Collaboration
  • Patient Counseling
  • Care Delivery
  • Community Resource Referrals
  • Critical Thinking
  • Strong Clinical Judgment
  • Documentation
  • Accurate Documentation
  • Patient Care Assessment
  • Decision-Making
  • Patient and family advocacy
  • Microsoft Office
  • Attention to Detail
  • ICD-10
  • Direct Patient Care
  • CPR/AED
  • Preventive Healthcare
  • Vitals monitoring
  • Medication and IV administration
  • Nursing Performance Assessment
  • Specialized Healthcare Referrals
  • Tracheostomy Care
  • Medical Procedure Preparation
  • Student Precepting
  • Medical Recordkeeping
  • Acute care expertise
  • Intake and discharge
  • Heartsaver CPR AED (CPR AED)
  • Prehospital Trauma Life Support
  • Immunizations and Vaccinations
  • Healthcare Program Planning
  • Pediatric Emergency Assessment, Recognition and Stabilization (PEARS)
  • Insulin medication assistance
  • RUG certified
  • Well versed with handling Medicare, and Medicaid patients and accounts

Other Jobs

  • Cardenas AutoPlex Bookkeeping/Cashier
  • Little Ceasers Assistant Manager
  • Mary Kay Representative

References

References upon request

Languages

Spanish
Native or Bilingual

Timeline

Star Plus Waiver RN Case Manager

Molina Healthcare
01.2022 - Current

RN Case Manager/Service Coordinator Star Plus Waiver

Cigna Health Spring
05.2015 - 12.2021

Pediatric Private Duty Registered Nurse

All About Kids Home Health
05.2010 - 05.2015

Newborn ICU Registered Nurse

Valley Baptist Medical Center
06.2009 - 09.2010

Agent/Quality Control/Training

Advance Call Center Tech
03.2002 - 01.2006

Sales Associate/ Assistant Manager

Ann Taylor
02.2000 - 03.2003

Selling Specialist

Foley's (Men's Dept.)
01.1999 - 02.2000

Sales Associate/Assistant Manager/Key holder(Team Lead appointed by Manager)

Sears Roebuck (Men's Dept.)
03.1996 - 06.1998

Associate Degree of Applied Science in Nursing -

University of Texas at Brownsville and Texas Southmost College

Nursing

Texas State Technical College

Tomball College

Indiana University Northwest

High School Diploma -

Merrillville High School

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Rose Macias