MARIA LOPEZ, RN
Chicago,IL
Summary
Dependable Utilization Review Nurse with many years promoting expertise in healthcare industry. Uses critical thinking and problem solving skills with understanding of Medicare guidelines.
Organized candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Seeking to maintain full-time position that offers professional challenges utilizing interpersonal skills, excellent time management and problem-solving skills.
Overview
11
11
years of professional experience
Work History
Nurse Case Management Senior Analyst RN
Cigna
01.2018 - Current
- Review request for medical necessity using Medicare guidelines, referring to the medical Director those that require additional expertise
- Provide timely review of authorization request from member and providers
- Perform clinical review for authorizations request using appropriate criteria (NDC/LCD, InterQual and MCG)
- Complete medical necessity and level of care reviews for requested services using appropriate criteria
- Make outreaches to members and provider’s to obtain clinical documentation required for review
- Provide accurate and complete documentation with rational used to approve request
- Provide appropriate referral to Case Management when needed
- Identify appropriate alternative and non-traditional resources and demonstrate creativity in managing each case to fully utilize all available resources
- Maintain accurate records of all communications and interventions
- Conduct outreaches to members and providers with decision.
Care Coordinator LPN
Cigna
12.2014 - 12.2017
- Telephonically working with members to Complete Health Risk Screening and Risk Triggering Comprehensive assessments
- Facilitate inbound/ outbound calls to assist members, providers and facilities
- Works with member, member’s family and providers to develop a comprehensive individual care plan and facilitate appropriate referrals
- Uses clinical judgment to identify physical and behavioral health needs
- Acts as a liaison and facilitates the coordination of benefits and resources
- Telephonically manage moderate and low risk stratified members
- Act as trainer to new staff
- Act as Lead Care Coordinator for supplemental HEDIS chart retrieval
- Perform face to face visits with members in facility settings.
- Collaborated with interdisciplinary teams to establish proper patient care and provide education to patients and family members.
Office Manager/LPN
Lincona Medical
01.2013 - 12.2016
- All managerial duties: In and outpatient billing, payroll, bill payment, create SOP manuals, CME tracking for M.D
- License renewal, Credentialing, managing inventory & budget etc
- Triage & follow up calls
- Provides training and education to providers and staff around ongoing policies and procedures, quality initiative, STARS and HEDIS
- Organize and facilitate monthly operational meetings with providers
- Research trend analysis reports and report financial performance to providers
- Perform analysis for at risk members, provider patients with results and education on corrective turn around
- Prior authorization & referrals
- Perform chart reviews for audits for insurance companies.
- Managed various general office duties such as answering multiple telephone lines, completing insurance forms, and mailing monthly invoice statements to patients.
- Performed routine evaluations of each patient's status, needs, and preferences.
- Obtained patient vital signs and input/output measurements from inpatients.
- Educated patients and caregivers on medical diagnoses, treatment options, chronic disease self-management and wound management.
- Gathered lab specimens, ordered testing, and interpreted results to diagnose patients.
- Answered incoming phone calls from patients to provide basic assistance and triage medical concerns.
- Administered medications and injections to patients.
- Assessed patients' temperature, pulse, and blood pressure and recorded in electronic medical records.
- Reviewed patient history to verify conditions and current medications.
- Responded to patient requests with appropriate clinical and personal assistance.
- Provided patient education on health care issues and prescribed medications.
Education
RN -
Ambria College Nursing
Hoffman Estates, IL01.2021
LPN -
Northwestern Institute of Health & Technology
Chicago, IL01.2013
Medical Assistant -
Olympia College
Skokie, IL01.2001
Skills
- Medicare Guidelines NCD, LCD/ Policy Guidelines/ MCG/ InterQual
- Evidence-Based Decision Making
- Knowledge of Business Operations
- Microsoft Word & Excel/ Office/
- CPT/ICD 10/ EMR, EHR
- Team Collaboration and Leadership/ Precepting & Training staff
- Interpersonal and Written Communication/ Deadline Adherence/ Analytical Thinking
- Accurate Documentation and reporting/ Relaying Complex information/Documentation Proficiency
- Physician Consultations/Interdisciplinary Collaboration
- Care Coordination/ Case Management/Resource Identification/ Community Resources
- Resource Management/ Referral Coordinator/ Specialized Healthcare Referrals
- Clear Patient Communication/Positive Attitude
- Critical Thinking/ Problem-Solving/ Decision -Making/ Attention to Detail/ Organization and Multitasking
- Indirect Patient Care
Timeline
Nurse Case Management Senior Analyst RN
Cigna
01.2018 - Current
Care Coordinator LPN
Cigna
12.2014 - 12.2017
Office Manager/LPN
Lincona Medical
01.2013 - 12.2016
RN -
Ambria College Nursing
LPN -
Northwestern Institute of Health & Technology
Medical Assistant -
Olympia College
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