Melvin Efrece
Coral Springs,FL
Summary
Knowledgeable Licensed Practical Nurse with 24+ years in the Healthcare industry, seeking a Nursing role. Years of experience in patient care, EHR systems, utilization management, quality management and provider education. Reliable candidate ready to take on challenges using problem solving and task prioritization skills to help team success.
Overview
18
18
years of professional experience
1
1
Certification
Work History
Quality Management / HEDIS Specialist
Simply Healthcare Plans / Elevance Health
Miami
01.2012 - Current
- Performed medical records request and collections. Conduct comprehensive medical record abstraction and research to support HEDIS and the Medicare Stars program compliance.
- Demonstrating proficiency in multiple EHR systems Lead quality of care investigations based on member complaints and implemented provider education initiatives to align with plans standards.
- Performed utilization management reviews to evaluate the necessity, appropriateness and efficiency of healthcare services.
- Analyzed healthcare data to identify trends, driving improvements in service delivery and operational efficiency.
- Collaborated with cross-functional teams to streamline processes, enhancing overall workflow effectiveness.
Assistant Manager (Part-time)
SoFlo Rubio's Coral Distributor
01.2022 - 01.2025
- I managed the floor team, making sure the sales floor and bins were organized ensuring inventory was properly maintained. Reconcile revenue, collected and reconciled all receipts and payments from cash, credit card sales and online purchases and ensured everything balanced out at the end of the day. Created the staff schedule for part time employees on a weekly basis and for full time employees on a monthly basis.
Configurations Analyst
Preferred Care Partners
01.2011 - 01.2012
- Audited existing system configurations to pinpoint enhancements and align with medical insurance industry regulations. Engaged in system management cycle, scrutinizing and sanctioning amendments to system set ups. Assessed contemporary technologies and tools for potential to heighten system configuration management efficacy. Analyzed medical coding arrangements, categorizing ICD-10 and CPT codes appropriately.
- Conducted reviews of inpatient and outpatient services to ensure they are medically necessary and meet established guidelines. Evaluates patient medical records, treatment plans, and clinical documentation to determine if care is appropriate and necessary. Worked closely with the Medical Director(s), requesting physicians, case managers, and other healthcare team members to develop effective care plans and discharge strategies. Maintained accurate and detailed documentation of utilization review activities and outcomes.
- Developed and maintained documentation for configuration processes and procedures to enhance operational efficiency.
- Analyzed system configurations to ensure compliance with regulatory standards and internal policies.
- Collaborated with cross-functional teams to troubleshoot and resolve configuration-related issues, improving system performance.
- Conducted regular audits of configuration settings to identify discrepancies and recommend corrective actions promptly.
Medical Staff Team Lead
Broward Correctional Institute
01.2008 - 01.2011
- Oversaw daily operations of the infirmary, ensuring efficient management of inmate sick calls and medical appointments. Managed the treatment of inmates having a medical emergency, mental health crisis or going through drug induced withdrawals. Coordinated initial medical screenings for new inmates to include addressing immediate health concerns, and chronic care requirements. Administered comprehensive medication distribution protocols throughout the facility, maintaining rigorous standards of care.
Education
Certified Professional Coder -
AAPC
LPN Certification -
US ARMY ACADEMY OF HEALTH SCIENCES
San Antonio, TX01-2000
Skills
- EHR Platform Proficiency
- MS Office Literacy
- Data Analysis
- Patient & Family Education
- Medication Administration
- Problem Solving
- Leadership
Certification
- Compact State Licensed Practical Nurse # PN511188
- BLS Certified
- NPI # 1821889262
LANGUAGES
English: Fluent
Spanish: Fluent
Timeline
Assistant Manager (Part-time)
SoFlo Rubio's Coral Distributor
01.2022 - 01.2025
Quality Management / HEDIS Specialist
Simply Healthcare Plans / Elevance Health
01.2012 - Current
Configurations Analyst
Preferred Care Partners
01.2011 - 01.2012
Medical Staff Team Lead
Broward Correctional Institute
01.2008 - 01.2011
Certified Professional Coder -
AAPC
LPN Certification -
US ARMY ACADEMY OF HEALTH SCIENCES
EXPERIENCE HISTORY
- Informatics Data Input & Management
- Geriatric Care
- Pediatric Care
- Chemical Dependence Rehabilitation
- Mental Health Care
- Remote Managed Healthcare
- Customer Service
- Call Center Management
- Remote Work Environment