Michelle Martinez
Indianapolis,IN
Summary
To obtain a position that will expand my nursing education, skills and utilize it to enforce facility’s operation.
Overview
17
17
years of professional experience
1
1
Certification
Work History
Nurse Medical Management I
Profession Management Enterprise
09.2023 - Current
- Conducting pre-certification, continued stay review, care coordination, or discharge planning for appropriateness of treatment setting reviews to ensure compliance with applicable criteria, medical policy, and member eligibility, benefits, and contracts
- Ensures member access to medically necessary, quality healthcare in a cost-effective setting according to contract
- Consult with clinical reviewers and/or medical directors to ensure medically appropriate, high-quality, cost-effective care throughout the medical management process
- Collaborates with providers to assess member’s needs for early identification of and proactive planning for discharge planning
- Facilitates member care transition through the healthcare continuum and refers treatment plans/plan of care to clinical reviewers as required and does not issue non-certifications
- Facilitates accreditation by knowing, understanding, correctly interpreting, and accurately applying accrediting and regulatory requirements and standards.
Lead I (Utilization Management for Inpatient Concurrent Reviews)
UST Global
06.2018 - 09.2023
- Performs review of inpatient admissions including emergent, elective admissions to the hospitals as well as transfer to a lower level of care such as in an acute rehabilitation facility, skilled nursing facility or LTACH
- Coordinates patient’s discharge planning needs with the healthcare team
- Prepares cases for review by medical director when condition or treatment plan varies from established guidelines
- Works with providers to obtain the information pertinent to evaluating treatment plan, medical necessity, appropriateness of care, timely progression of services and appropriate application of available benefits.
Concurrent Review Nurse
Managed Health Services
08.2016 - 06.2018
- Perform onsite review of emergent/urgent and continued stay requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
- Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
- Collaborate with various staff within provider networks and discharge planning team electronically, telephonically, or onsite to coordinate member care
- Educate providers on utilization and medical management processes
- Provide clinical knowledge and act as a clinical resource to non-clinical team staff
- Enter and maintain pertinent clinical information in various medical management systems.
Nurse
Norwood Crossing
04.2015 - 04.2016
- Identifies patient care requirements by establishing personal rapport with potential and actual patients and other persons in position to understand care requirement
- Establishes a compassionate environment by providing emotional, psychological and spiritual support to patients, friends and families
- Promotes patient’s independence by establishing patient care goals: teaching patients/friends, and family to understand condition, medications and self-care skills
- Assures quality of care by adhering to therapeutic standards, measuring health outcomes, against patient care goals and standards, making or recommending necessary adjustments, following hospital and nursing division’s philosophies and standards of care set state board of nursing, state nurse practice act, and other governing agency regulations
- Resolves patient problems and needs by using multidisciplinary strategies
- Protects patients and employees by adhering to infection-control policies and protocols, medication administration and storage procedures and controlled substance regulations.
Nurse
Vitacare Health Services
08.2014 - 04.2015
- Providing case management as described in state regulations for all cases including nursing and therapy services
- Making the initial evaluation visit as applicable and re-evaluating each patient’s nursing needs on a regular basis
- Providing nursing services, treatments and diagnostic procedures requiring specialized skills and assuming full responsibility for each patient
- Observing, reporting, symptoms, reaction to treatment, drugs and changes in the patient’s physical and emotional condition.
Nurse
Samland home health care
07.2014 - 09.2014
- Initiating preventive and rehabilitative nursing procedures as appropriate for the patient’s care and safety
- Maintaining clinical and progress notes for each patient receiving care and providing progress reports to their physician
- Coordinating services for patients as needed to other agencies and health care providers as appropriate
- Providing supervision of home health aides and preparing written instructions for care provided by home health aides
- Maintaining confidentiality of patient and agency matters
- Submitting required documentation in a timely manner
- Reporting observed or suspected child or adult abuse pursuant to mandated requirements.
NURSE TEAM LEAD (UTILIZATION REVIEW)
HEALTH CARE CORPORATION OF AMERICA HEALTH CONNECTIONS
05.2012 - 12.2013
- Functions include coaching, mentoring, providing orientation and support of new staff, performing assessment through service observations and case reviews, monitoring daily staffing requirement to include work assignment supervision
- Managed various report activities to ensure metrics are met, providing help to staff in working and completing partial prep, chronologies and full preparations as assigned, maintaining productivity, quality and other service standards and metrics.
UTILIZATION REVIEW NURSE
EXL SERVICE PHILIPPINES
06.2010 - 02.2012
- Evaluated treatment or service request for medical necessity and appropriateness using nursing judgment, treatment criteria guidelines and physician advisor/peer review referral process
- Conduct first level prospective, concurrent or retrospective review, employing standardized evidence-based review criteria and treatment parameters in order to authorize services
- Identified cases where additional information is required to complete the review and/or identify potential medical necessity cases
- Negotiate alternative treatment plans within treatment criteria guidelines
- Utilized clinical knowledge and appropriate written and verbal skills to communicate with treating medical providers.
NURSING CLINICAL INSTRUCTOR
DE LA SALLE HEALTH SCIENCES CAMPUS
06.2007 - 10.2009
- Demonstrates and teaches patient care in classroom and clinical units to nursing students and instructs students in principle and application of physical, biological and psychological subjects related to nursing
- Lectures to students, conducts and supervises laboratory works, issues assignments, supervises student nurses and demonstrates patient care in clinical units of hospitals
- Prepares and administers examinations, evaluates student’s progress and maintains records of student classroom and clinical experience
- Cooperates with medical and nursing personnel in evaluating and improving teaching and nursing practices in the hospital and community.
Education
Bachelor of science in nursing -
De La salle health sciences campus
04.2005
Skills
- Worker’s Compensation
- Utilization Review
- Managed Care
- Microsoft Word
- Excel
- Outlook
Certification
- Registered Nurse license in the state of IN
- Registered Nurse – Compact license
- Care Guideline Specialist by MCG
Personal Information
Title: RN, BSN
Timeline
Nurse Medical Management I
Profession Management Enterprise
09.2023 - Current
Lead I (Utilization Management for Inpatient Concurrent Reviews)
UST Global
06.2018 - 09.2023
Concurrent Review Nurse
Managed Health Services
08.2016 - 06.2018
Nurse
Norwood Crossing
04.2015 - 04.2016
Nurse
Vitacare Health Services
08.2014 - 04.2015
Nurse
Samland home health care
07.2014 - 09.2014
NURSE TEAM LEAD (UTILIZATION REVIEW)
HEALTH CARE CORPORATION OF AMERICA HEALTH CONNECTIONS
05.2012 - 12.2013
UTILIZATION REVIEW NURSE
EXL SERVICE PHILIPPINES
06.2010 - 02.2012
NURSING CLINICAL INSTRUCTOR
DE LA SALLE HEALTH SCIENCES CAMPUS
06.2007 - 10.2009
Bachelor of science in nursing -
De La salle health sciences campus
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