MARIDEL ANNE PLAZA BSN RN ACM-RN
St. Johns,USA
Summary
Dynamic Case Manager with a proven track record in utilization management, care coordination, and interdisciplinary collaboration in an acute care setting. Adept at handling high caseloads, collaborative professional possessing excellent clinical knowledge and judgment, combined with strong documentation and problem-solving abilities.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Utilization Review Case Manager
Hackensack University Medical Center
Hackensack, NJ
11.2018 - 05.2025
- Utilized case management software and databases for efficient information tracking.
- Monitored client progress through regular follow-ups and case reviews.
- Collaborated with healthcare team to improve care quality, reduce costs and gauge patient progress.
- Facilitated communication between payers, providers and patients concerning authorization issues or concerns.
- Communicated with managed care organizations, or vendors, on a regular basis
- Maintained up-to-date knowledge of health plan benefits, policies, procedures, regulations, coding guidelines.
Precertification Nurse
Genesis Healthcare Corporation
Foothill Ranch, CA
03.2016 - 03.2019
- Assessed the medical necessity of requested services and ensured that all necessary documentation was submitted for approval processes.
- Reviewed and verified patient insurance coverage to ensure authorization criteria were met.
- Resolved issues related to pre-authorization process with payers and other external entities.
- Collaborated with providers, payers, and members to obtain prior authorizations for skilled nursing and rehab services.
RN Supervisor/MDS Plan Coordinator
Lake Forest Nursing Center
Lake Forest, CA
08.2014 - 03.2016
- Coordinated completion of resident assessments in accordance with current federal and state regulations
- Coordinated timely submission of all required documents including MDS forms, Care Area Assessments, and other regulatory paperwork.
- Developed individualized plans of care for each resident based on assessment findings.
Staff Nurse/ IRF PAI Coordinator
Kingwood Medical Center
Kingwood, TX
04.2013 - 06.2014
- Collaborated closely with interdisciplinary team members to ensure timely completion and submission of IRF PAI tool for reimbursement.
- Actively participated in multidisciplinary rounds discussing complex cases with members of the healthcare team.
- Provided direct nursing care such as wound dressing changes, IV therapy, medication administration and patient education.
Staff Nurse
Doctors Hospital at Renaissance
Edinburgh, TX
08.2012 - 04.2013
- Provided direct patient care, including medication administration, IV therapy, wound care, etc.
- Managed multiple tasks simultaneously while maintaining quality standards of care.
- Assisted physicians with exams, lab tests or other procedures as ordered.
MDS Coordinator
JDT Medical Rehab Center
Lincoln Park, NJ
04.2010 - 08.2012
- Researched new developments in Medicare and Medicaid reimbursement policies related to long-term care facilities.
- Facilitated team meetings with members from other departments to discuss resident issues and concerns related to the MDS process.
- Conducted assessments to determine the resident's functional and cognitive abilities, as well as their level of care needs.
- Monitored residents' progress and updated MDS records accordingly.
- Collaborated with interdisciplinary teams to develop comprehensive care plans.
Education
Bachelor of Science - Nursing
Xavier University-Ateneo de Cagayan
Philippines03.2009
Skills
- Utilization Review
- Discharge planning coordination
- Care Coordination
- Acute care expertise
- Interdisciplinary collaboration
- Problem solving
- Patient advocacy
- Positive attitude
- Critical thinking
- Utilization management
- Documentation and reporting
- MS office
- Documentation proficiency
Certification
- Accredited Case Manager (ACM-RN)
- BLS Certified
- Registered Nurse (MULTI-STATE Compact License)
Timeline
Utilization Review Case Manager
Hackensack University Medical Center
11.2018 - 05.2025
Precertification Nurse
Genesis Healthcare Corporation
03.2016 - 03.2019
RN Supervisor/MDS Plan Coordinator
Lake Forest Nursing Center
08.2014 - 03.2016
Staff Nurse/ IRF PAI Coordinator
Kingwood Medical Center
04.2013 - 06.2014
Staff Nurse
Doctors Hospital at Renaissance
08.2012 - 04.2013
MDS Coordinator
JDT Medical Rehab Center
04.2010 - 08.2012
Bachelor of Science - Nursing
Xavier University-Ateneo de Cagayan