MARIA L. ARROZA
Carson,USA
Summary
Results-driven care management professional with over five years of experience in Utilization Management, demonstrating expertise in denial management strategies and regulatory compliance alongside exceptional communication skills.
Overview
17
17
years of professional experience
Work History
LVN, Authorization Denial Nurse
Health Physicians Medical Group
Sacramento, California
04.2024 - Current
- Perform all functions of the UM nurse reviewer.
- Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards.
- Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request.
- Ensures the denial reason is in the appropriate grade level and is easily understandable.
- Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial.
- Collaborates with UM compliance for continued quality improvement efforts for adverse determinations.
- Meets or exceeds productivity targets.
- Performs additional duties as assigned.
LVN, Utilization Management Compliance (CDU)
Optum
Chatsworth, California
09.2020 - 05.2024
- Consistently exhibits behavior and communication skills that demonstrate Optum’s commitment to superior customer service, including quality, care and concern with each internal and external customer.
- Perform all functions of the UM nurse reviewer.
- Composes denial letter in a manner consistent with federal regulations, state regulations, health plan requirements and NCQA standards.
- Constructs denial notices to ensure the intended recipients can understand the rationale for the denial of service and is specific to member’s condition and request.
- Ensures the denial reason is in the appropriate grade level and is easily understandable.
- Ensures the UM nurse reviewer has provided the appropriate reference for benefits, guidelines, criteria or protocols based on the type of denial.
- Consults with the medical director on cases that do not meet the established guidelines for a compliant denial notice for determination.
- Escalates non-compliant cases to UM compliance and consistently reports on denial activities.
- Collaborates with UM compliance for continued quality improvement efforts for adverse determinations.
- Identifies gaps in training or process impacting the overall compliance of adverse determinations and communicates in writing an effective performance improvement solution.
- Meets or exceeds productivity targets.
- Uses, protects, and discloses Optum patients’ protected health information (PHI) only in accordance with Health Insurance Portability and Accountability Act (HIPAA) standards.
- Performs additional duties as assigned.
LVN Care Manager, Utilization Management
HealthCare Partners Medical Group
Costa Mesa, California
10.2014 - 09.2020
- Company Overview: Costa Mesa, California
- Applies Utilization Review Management process to ensure continuity of care throughout the health care continuum including review and authorization of services applying evidence-based guidelines.
- Assures review turnaround times adhere to timeliness standards set by regulatory requirements and establish productivity and quality guidelines.
- Able to dependently research and determine the information necessary to complete medical necessity review.
- Identifies appropriate clinical guidelines necessary to accurately perform medical necessity review.
- Follow all department P&Ps as applicable to job.
- Demonstrates the ability to consistently utilize the computer system and software for referral review process.
- Prepares case specific, including clinical information, correspondence for physician review or Medical Director.
- Demonstrates the ability to apply and/or to explain managed care principles to others, i.e. contracted, non-contracted, full risk, shared risk, in and out of network, etc.
- Works with Medical Director to make authorization determination using clinical care guidelines and clinical analysis of relevant chart documentation.
- Able to Initiate and complete the denial process for services deemed to be non-covered benefits or not medically necessary.
Vice President of Operations
Royal Majesty Home Care
Long Beach, California
09.2008 - 10.2014
- Directs and coordinates activities of Healthcare Partners and Talbert Medical Group department including, intake, staffing, medical records and aids in formulating and administering agency policies by performing duties personally or through subordinate staff.
- Oversee the operations of Healthcare Partners Medical Group and Talbert Medical Group department which includes intake, staffing, care management, QA, Medical records.
- Manages 180-220 clients on a regular basis.
- Reviews analyzes of activities, costs, operations, and forecasts data to determine progressions towards goals.
- Meets regularly with nurses, therapists, social workers, and other healthcare team members to ensure quality care and optimal outcomes.
- Coordinates with insurance company/Medical groups on weekly basis to update patient’s progress.
- Coordinates patient care, including need for therapy services, psychosocial needs, and aide services and make appropriate referrals, as needed.
- Continually assesses patient’s eligibility for home health care and facilitate medical reviews as needed.
- Work with insurance companies / medical groups to obtain precertification/ authorization as well as send medical information on a regular basis for continued certification/authorization and Identify needs and necessary interventions, including chance of level of care.
- Monitors visit frequency and duration by reviewing physician’s orders and comparing to the plan of care and documentation.
- Audits charts, actively manages necessary chart paperwork and maintains open communication with field staff to resolve deficiencies.
- Communicates results of laboratory test and other diagnostic procedure with MD.
- Makes patient home visits as needed.
Education
Licensed Vocational Nurse -
Summit Career College
Anaheim, CA07.2009
Skills
- Client data management
- Referral management systems
- Epic and Tapestry expertise
- Case management software
- Microsoft Office suite
- Wound care techniques
- Negative pressure wound therapy
- Medicare and Medi-Cal knowledge
- CMS regulations compliance
- JCAHO standards adherence
- Commercial health plans expertise
- Milliman care guidelines application
- Utilization review processes
- Denial management strategies
- Clinical documentation practices
- Regulatory compliance knowledge
- Time management proficiency
References
References available upon request.
Timeline
LVN, Authorization Denial Nurse
Health Physicians Medical Group
04.2024 - Current
LVN, Utilization Management Compliance (CDU)
Optum
09.2020 - 05.2024
LVN Care Manager, Utilization Management
HealthCare Partners Medical Group
10.2014 - 09.2020
Vice President of Operations
Royal Majesty Home Care
09.2008 - 10.2014
Licensed Vocational Nurse -
Summit Career College
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