Summary
Overview
Work History
Education
Languages
Timeline
Generic

Mayra Castellanos

Valencia,CA

Summary

Recent graduate nurse with a strong passion for providing compassionate patient care, fostering engagement, facilitating effective communication, and delivering comprehensive education. Demonstrated ability to build and sustain strong relationships with physicians, nursing staff, administrative teams, and patients/families to ensure exceptional experiences and optimal health outcomes.

Overview

15
15
years of professional experience

Work History

Home Health LVN

Choice Home Health
08.2024 - Current
  • Promoted continuity of care by maintaining detailed documentation of patients' health status, interventions, and outcomes.
  • Provided emotional support and practical guidance to patients during challenging transitions to home-based care.
  • Enhanced the recovery process for patients through effective communication and collaboration with interdisciplinary healthcare teams.
  • Assisted patients with daily living activities, including bathing, dressing, grooming, meal preparation, and mobility support.

Quality Improvement Coordinator

WelbeHealth
05.2023 - Current
  • Developed quality improvement plans and operational guidelines in accordance with PACE standards.
  • Documented compliance and quality assurance issues.
  • -Evaluated the competency of clinical staff and recommended areas for improvement.
  • Conducted root cause analyses on incident reports.
  • -Generated monthly and quarterly reports for the Health Plan Management System (HPMS).
  • Audited appeals and grievances, providing suggestions for process enhancements.
  • Managed the department inbox using Athena and Outlook, and reviewed Power BI reports for grievances.
  • -Collaborated with the Interdisciplinary Team to address recurring falls among participants.

Quality Improvement Manager

Cano Health
11.2021 - 12.2022
  • Analyze HEDIS/STAR rates, identify barriers to improvement, and create interpretive exhibits.
  • -Conduct training on HEDIS/STAR measures and data collection strategies.
  • Provide expertise to the training department on STAR/HEDIS measures and collection tools.
  • Participate in NCQA HEDIS or Health Plan audits.
  • - Collaborate with physicians to implement clinical quality initiatives.
  • -Develop and monitor clinical quality improvement initiatives in the assigned region.
  • Assist with audits to ensure quality indicators and performance metrics are met.
  • -Maintain the risk quality pursuit database and report biweekly to providers on HEDIS gap closures.
  • Prepare and negotiate contracts for Primary Care Physicians and Specialists.
  • -Work with Network Support staff and Medical Management to address network needs.
  • Act as the internal liaison for Database, Claims, Customer Service, Medical Management, and Quality Management Departments.

QA/QI Supervisor

Southern California Medical Center, Inc.
09.2020 - 11.2021
  • Develop and conduct training sessions and materials.
  • Assist in managing regulatory agency inspections.
  • Perform audits of clinical investigations and document findings.
  • Work with the Chief Medical Officer to address Quality Improvement (QI) issues.
  • Oversee provider chart audits and monthly QI reporting.
  • Manage provider enrollment, credentialing, and training.
  • Identify staff education needs with the Director of Operations.
  • Conduct bi-annual clinic audits and assist with risk management reporting.
  • Train staff on HEDIS/STAR measures and data collection.
  • Participate in NCQA HEDIS or Health Plan audits.
  • Oversee QIC staff and referral management.
  • Address patient grievances and coordinate state program submissions.
  • Prepare and negotiate provider contracts for primary care physicians and specialists.

QA Clinical Coordinator/Wound Care

Omni Wound Physicians
11.2018 - 09.2020
  • Review of medical documentation submitted by providers to comply with CMS guidelines for billing and distribution to skilled nursing facilities, home health, and hospice agencies.
  • Wound staging and recommendations for appropriate wound dressings.
  • Orders for antibiotics, wound vacs, and wound care supplies.
  • Collaboration with MDs, PAs, and NPs to provide wound care, management in-home, in skilled nursing facilities, boarding homes, and assisted living facilities.
  • Assistance provided to healthcare providers with procedures and wound dressing changes.
  • Verification of insurance and patient eligibility.
  • Processing referrals received from Home Health services, skilled nursing facilities, hospices, and assisted living facilities.
  • Coordination of G-tube replacements.

Appeals and Grievance Coordinator

Health Net
04.2017 - 06.2018
  • Researched complaints and appeals from administrative members to ensure timely resolution.
  • Documented the outcomes of complaints, appeals, and dispositions at all levels, including notifications to providers and members, in accordance with state and federal guidelines.
  • Compiled case files on clinical member and provider appeals for review by the medical director.
  • Drafted clinical complaint resolution letters with guidance from clinical staff.
  • -Generated acknowledgment and resolution letters for complaints, appeals, and provider disputes.

Quality Improvement- Grievance and Appeals Coordinator

Regal Medical Group
11.2014 - 11.2017
  • Conducts reviews of appeals and statements of concern, formulating timelines and findings, and discussing them with the Medical Director as appropriate.
  • -Processes appeals in a timely manner, which includes reviewing applicable benefits, claims, denial reasons, authorizations, and eligibility. Engages with the Medical Director to make decisions on reconsiderations, overturns, or corrective action plans as necessary.
  • Manages a heavy workload with frequent interruptions and shifting priorities in a fast-paced environment while ensuring all work is completed accurately and on time.
  • Assists with special projects, such as taking minutes, distributing credentialing materials, providing after-hours support, ensuring access availability, and addressing questions from the team regarding cases.

Intake Coordinator and Medical Billing

AV Respiratory Services
02.2013 - 05.2014
  • Responsible for processing payments, adjustments, and denials in accordance with established guidelines.
  • Assists with oxygen setups, pulse oximetry testing, and equipment sales.
  • Collaborates with hospitals, clinics, and facilities to manage service requests from members.
  • Resolves patient equipment issues through troubleshooting.
  • Verifies insurance eligibility and benefits.
  • Reviews overnight pulse oximetry test results and provides written summaries to the doctor's office.
  • Available for after-hours on-call support.

Certified Medical Assistant (CMA) and Medical Billing

Dr. Haixin Xu, Inc
05.2010 - 02.2013
  • Sanitized and organized exam rooms and medical equipment.
  • Guided patients to exam rooms, addressing questions and preparing for exams.
  • Assisted physicians with procedures, ensuring comfort and precision.
  • Delivered compassionate care, addressing patient concerns.
  • Improved clinic efficiency by documenting patient information and updating records.
  • Conducted preliminary evaluations, including weight, temperature, and blood pressure.
  • Educated patients on preventative care to reduce future health risks.
  • Executed diagnostic tests for swift diagnoses and treatment plans.
  • - Prepared lab specimens and conducted EKGs as needed.

Education

Licensed Vocational Nurse -

North-West College
Van Nuys, CA
06.2024

Medical Assistant -

Kaplan College
Panorama City, CA
11.2010

High school diploma -

James Monroe High School
North Hills, CA
06.2008

Languages

English
Spanish

Timeline

Home Health LVN

Choice Home Health
08.2024 - Current

Quality Improvement Coordinator

WelbeHealth
05.2023 - Current

Quality Improvement Manager

Cano Health
11.2021 - 12.2022

QA/QI Supervisor

Southern California Medical Center, Inc.
09.2020 - 11.2021

QA Clinical Coordinator/Wound Care

Omni Wound Physicians
11.2018 - 09.2020

Appeals and Grievance Coordinator

Health Net
04.2017 - 06.2018

Quality Improvement- Grievance and Appeals Coordinator

Regal Medical Group
11.2014 - 11.2017

Intake Coordinator and Medical Billing

AV Respiratory Services
02.2013 - 05.2014

Certified Medical Assistant (CMA) and Medical Billing

Dr. Haixin Xu, Inc
05.2010 - 02.2013

Licensed Vocational Nurse -

North-West College

Medical Assistant -

Kaplan College

High school diploma -

James Monroe High School

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