Michelle Leal
Boerne,TX
Summary
Self-motivated professional and highly adaptive promoting attention to detail and the drive to resolve issues effectively. Skilled Utilization Review Nurse offering talents in continuous assessments and clinical records oversight. Calm and poised in the most stressful environments. Ready to join new company to best enhance the organizational brand.
Overview
17
17
years of professional experience
Work History
Senior UM Concurrent Reviewer
Centene, Superior Health Services
San Antonio, TX
05.2012 - 12.2023
- Communicated effectively with providers regarding authorization status and service denials.
- Utilized knowledge of the principles of managed care organizations while performing concurrent review activities.
- Assessed patients' eligibility for coverage according to insurance guidelines.
- Conducted initial reviews of medical records to determine appropriateness of requested services.
- Performed concurrent review activities to ensure that treatments are medically necessary and meet quality standards.
- Participated in quality assurance initiatives designed to improve patient care outcomes.
- Provided support during appeals process when necessary by researching relevant documents and providing expert opinion where applicable.
- Provided feedback on utilization management cases to providers as needed.
- Interpreted clinical data from medical records and applied evidence-based criteria in order to make decisions regarding the appropriateness of care provided.
- As the lead concurrent review nurse I assessed performance of fellow nurses and motivated necessary change to meet department benchmarks.
RN-Special Care Nursery/Nursery Nurse
Bay Area Medical Center
Corpus Christi, TX
12.2006 - 01.2011
- Assessed and monitored the vital signs of newborns in special care nursery and Newborn Nursery.
- Administered medication, fluids, and nutrition as per physician orders.
- Coordinated with physicians and multidisciplinary team members regarding patient care plans.
- Developed health-care plans based on patients' needs and preferences.
- Maintained accurate records of patient information such as medical history, test results, treatments, and medications administered.
- Implemented safety protocols to ensure a safe environment for both patients and staff working in the special care nursery.
- Educated families on proper infant care techniques while in special care nursery.
- Provided emotional support to families with infants in special care nursery.
Education
Associate of Applied Science - Registered Nurse
Del Mar College
Corpus Christi, TX05-2006
High School Diploma -
Robstown High School
Robstown, TX05-1996
Skills
- Utilization review-utilization management
- Quality Improvement
- HIPAA Compliance
- Performing assessments
- Documentation And Reporting
- Inpatient Care
- Insurance Verification
- Patient Care Plans
- leading teams
- concurrent review
- discharge planning
References
References available upon request.
Timeline
Senior UM Concurrent Reviewer
Centene, Superior Health Services
05.2012 - 12.2023
RN-Special Care Nursery/Nursery Nurse
Bay Area Medical Center
12.2006 - 01.2011
Associate of Applied Science - Registered Nurse
Del Mar College
High School Diploma -
Robstown High School
Similar Profiles
Christine Chaduka -NgamalueChristine Chaduka -Ngamalue
Concurrent Review Nurse at Centene, Superior Health ServicesConcurrent Review Nurse at Centene, Superior Health Services
Kenneth Smith Jr.Kenneth Smith Jr.
Provider Services Specialist at Centene, Superior Health ServicesProvider Services Specialist at Centene, Superior Health Services
Carolyn IngramCarolyn Ingram
Bilingual Customer Service Representative at Centene, Superior Health ServicesBilingual Customer Service Representative at Centene, Superior Health Services
Fiona Ojunga RN BSNFiona Ojunga RN BSN
RN Case Manager at Centene, Superior Health ServicesRN Case Manager at Centene, Superior Health Services
DJ BohmanDJ Bohman
Manufacturing Technician at Albany Engineered CompositesManufacturing Technician at Albany Engineered Composites