Miguel Medina
Summary
Dynamic Registered Nurse with expertise in acute care, skilled in clinical documentation and patient advocacy, with years of experience in the health insurance sector/medical device sales industry. Proven ability to assess medical necessity, ensure compliance with healthcare regulations, and optimize patient outcomes. Strong clinical judgment to ensure high-quality patient care in diverse medical settings.
Overview
13
13
years of professional experience
Work History
REGISTERED NURSE
Penn Medicine
04.2024 - Current
- Delivered high-quality acute care to diverse surgical patients, enhancing patient recovery rates and ensuring optimal health outcomes.
- Graduated from the Vizient/AACN Nurse Residency Program, culminating in a professional presentation of an evidence-based project.
- Developed comprehensive nursing care plans based on diagnoses, desired outcomes, and evidence-based practices, ensuring high-quality patient care.
- Conducted thorough patient assessments, monitored vital signs, and recognized early signs of infection, initiating emergency interventions as needed.
- Actively participated in unit-based quality improvement initiatives focused on patient safety and infection reduction.
- Operated a wide array of medical equipment, including intravenous pumps, infusion devices, blood glucose monitors, electrocardiograms, and defibrillators.
- Educated patients and families extensively on disease processes, medications, discharge instructions, infection control, and follow-up care, facilitating informed decision-making.
- Collaborated effectively with the interdisciplinary team in patient admission, care planning, and discharge processes.
- Coordinated complex discharge planning services, liaising with case managers, social workers, providers, home health agencies, and rehabilitation/skilled nursing facilities to ensure seamless transitions of care.
- Advocated for patients' needs, ensuring responsible resource management and compliance with organizational policies and procedures.
- Analyzed patient charts to ensure appropriate care plans, patient status (inpatient, critical, observation), and orders were in place, demonstrating an understanding of documentation impact on care and billing.
MEMBER ADVOCATE
Conner Strong & Buckelew
09.2020 - Current
- Served as a primary point of contact for members and human resources, addressing complex inquiries related to group employee benefits and healthcare access.
- Functioned as a patient advocate and case manager, actively working to secure services, medications, and Durable Medical Equipment (DME) for members in need.
- Maintained thorough knowledge of current healthcare regulations, including CMS, Medicare, and Medicaid requirements, applying this knowledge to guide members and resolve issues.
- Successfully managed a high volume of complex cases, prioritizing reviews based on urgency and clinical impact to ensure timely resolution of patient access issues.
- Researched and resolved intricate service issues, including claims, enrollments, terminations, and billing discrepancies between members and insurance carriers.
- Initiated and managed follow-up on denied or unpaid claims, gathering essential clinical documentation and collaborating with clients/human resources to ensure appropriate processing and appeals.
- Engaged directly with hospitals, provider/doctor offices, insurance companies, laboratories, and pharmacies to research service issues and unpaid claims.
- Ensured appropriate billing and diagnosis codes (ICD-10) were utilized and applied InterQual criteria to determine claim eligibility and medical necessity.
- Provided critical support in the Prior Authorization and Appeals process, contributing to successful outcomes for members facing access barriers.
SALES CONSULTANT
AT&T
06.2019 - 09.2020
- Utilized a consultative sales approach to understand customer needs and recommended relevant offerings, strengthening customer relationships.
- Provided technical support for a wide array of devices and operating systems, demonstrating problem-solving and communication skills.
- Developed a strong understanding of technology and the telecommunications industry, adapting to evolving sales goals and consistently excelling.
- Conducted fraud and audit investigations with the district manager, highlighting attention to detail and compliance.
- Analyzed sales performance metrics to identify trends, enabling strategic adjustments that led to measurable improvements in sales targets.
- Conducted targeted product training for sales teams, fostering knowledge transfer that empowered consultants to exceed sales quotas.
- Drove sales growth through effective product presentations and customer engagement strategies.
OPTICIAN
National Vision Inc.
04.2012 - 07.2017
- Applied sales and service expertise to promote optical products, achieving sales targets.
- Engaged and trained health care providers (Optometrists) in new product launches, and how the feature/benefits provided solutions to patients.
- Conducted pre-eye exam vision screenings for patients using opthalmic medical equipments, and assisted optometrists in translation during eye exams.
- Assisted the Store Manager in analyzing logistical reports on store performance and sales trends.
- Trained all new hires in optics knowledge and sales techniques.
- Enhanced customer engagement by delivering tailored optical solutions, resulting in improved sales performance and customer satisfaction.
Education
Bachelor of Science - Nursing
Drexel University
Philadelphia, PA03.2024
Bachelor of Arts - Health Sciences
Rutgers University-Camden
Camden, N05.2022
KEY QUALIFICATIONS
- Reimbursement & Patient Access Expertise: Demonstrated ability to research and resolve complex claims, prior authorizations, and appeals, with a strong understanding of payer policies (Medicare, Medicaid, Commercial).
- Clinical Acumen & Patient Advocacy: In-depth knowledge of diverse patient conditions, treatment protocols, and the ability to advocate for patient needs within the healthcare system.
- Healthcare Regulations & Compliance: Thorough understanding and adherence to CMS, HIPAA, and other regulatory requirements impacting patient access and reimbursement.
- Communication & Education: Exceptional skills in translating complex medical and reimbursement information clearly to healthcare providers, patients, and internal teams.
- Problem-Solving & Analytical Skills: Proven ability to analyze patient charts, identify issues, and develop effective solutions for access and billing challenges.
- Interdisciplinary Collaboration: Experience fostering strong relationships and coordinating with physicians, case managers, social workers, and insurance carriers.
- Data & Documentation Management: Proficient in electronic health records (EPIC) and meticulous in documenting interactions for accurate claims processing and follow-up.
Timeline
REGISTERED NURSE
Penn Medicine
04.2024 - Current
MEMBER ADVOCATE
Conner Strong & Buckelew
09.2020 - Current
SALES CONSULTANT
AT&T
06.2019 - 09.2020
OPTICIAN
National Vision Inc.
04.2012 - 07.2017
Bachelor of Science - Nursing
Drexel University
Bachelor of Arts - Health Sciences
Rutgers University-Camden
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