Miriam Hernandez, LVN
Elk Grove,CA
Summary
Professional healthcare provider with strong background in patient care coordination and medical review processes. Expertise in clinical assessments, utilization management, and regulatory compliance. Known for effective team collaboration, adaptability, and delivering impactful results. Skilled in critical thinking, communication, and patient advocacy, ensuring optimal care and efficiency.
Overview
16
16
years of professional experience
1
1
Certification
Work History
Concurrent Review Nurse
Centene Corporation
03.2023 - Current
- Perform utilization review for Medi-Cal Managed Care population utilizing InterQual criteria and Medi-cal Ch. 7 criteria to determine medical necessity
- Assist providers with discharge planning to ensure members receive the appropriate level of care by providing resources and referrals to appropriate programs in order to facilitate a safe discharge plan and prevent inpatient recurrence
- Cross trained to assist with CalAim department in providing resources to low-income members
- Completed an average of 450 reviews per month with an accuracy of 97% – 100%
- Met all TAT for reviews, authorizations and NOA letters
- Improved patient outcomes by conducting thorough concurrent reviews and recommending appropriate care plans.
Lead Dispensing Nurse
Acadia Healthcare
11.2017 - 03.2020
- Oversaw methadone administration, monitored distribution, and documented responses
- Reviewed patient charts to ensure accurate completion and address any discrepancies
- Reconciled all medications (Methadone, Suboxone, Subutex) daily
- Maintained records of medications in stock and medication dispensed per DEA, State, and Federal protocol
- Improved patient safety through rigorous adherence to proper dispensing procedures and protocols.
- Reduced medication errors by maintaining precise documentation of dispensed medications.
Inpatient Case Manager
Choice Medical Group
02.2016 - 03.2017
- Identified patient level of care was accurate for patient’s current severity of illness and initiated case management services providing coordination of care related to discharge into the community
- Assessed patient needs for durable medical equipment, home health nursing, home infusion therapy, and psycho-social support to prevent hospital readmission
- Provided authorizations as needed for the delivery of care in alternate settings
- Communicated with payers and/or their representatives regarding reason for admissions, the expected and ongoing plan of care, continued justifications for inpatient stay, discharge criteria and plans for post discharge care
- Reduced the number of readmissions by 65% by proactively following up with patient post discharge and making sure all medical needs were met
- Decreased patient length of stay in hospital by 50% by monitoring level of care and arranging in-home care accordingly
Medical Administrator
Medcor
05.2013 - 02.2016
- Managed on site clinic for Target Warehouse and provided routine and emergency care of occupational and non-occupational illnesses and injuries
- Conducted pre-employment drug screens and physicals
- Monitor and record progress of treatment of employees with Workers Compensation claims as well as liaison between workers comp
- Claim adjusters and employer
- Reduced the amount of Workers Compensation claims by 85% by treating all in-house injuries and recommending in-house light duty per Medcor protocol
- Administer audiology testing to all warehouse employees per the CAOHC regulations
- Generated monthly and quarterly reports of all medical, open workers comp, claims, and daily activities occurring in the facilities
- Attended all startup shift meeting and discussed safety topic of the weeks with all employees and participated in warm up exercises
- Provided Cardiopulmonary Resuscitation training twice a year for all employees
Patient Care Coordinator
Bloomington Health Services
06.2012 - 05.2013
- Provided case management for all diabetic IEHP patients to improve patient follow through in treatment care
- Conducted in person and remote Diabetes education classes for all IEHP diabetic patients
- Identified all at risk patients and scheduled 1:1 phone calls to identify ongoing medical issues and resolve obstacles preventing patient from getting care needed
- Point of contact for all IEHP patients for all treatment referrals
- Contacted and scheduled appointments for lab work in diabetic patients
- Reviewed all patient blood work results with primary care physician and adjusted plan of care accordingly
- Created incentive program that successfully encouraged patients to participate in treatment resulting in increased compliance with treatment
Charge Nurse
Pilgrim Place Health Services
02.2009 - 06.2012
- Accountable for day-to-day care for 25-30 geriatric patients through the direct supervision of 6 CNAs
- Administer control narcotics assuming full responsibility for possession of keys
- Develop and implement nursing care plans and supervise patients, admissions and discharge procedures
- Liaison between patients, nurses, and physicians to address problems requiring immediate/long term resolve
- Assist staff nurses with initial assessment of patients upon admission
- Provide treatments and medications per physician order
- Attend all MDS meeting with nursing director and patient families and provide updates on treatments
Education
Nightingale College
Utah04.2026
Licensed Vocational Nurse Training (LVN) -
Northwest College
Riverside, CA06.2008
Skills
- Disease Management
- Patient Advocacy
- Case Management
- Utilization Review
- Occupational Health
- Discharge Planning
- Medicaid knowledge
- Managed Care
Certification
- Licensed Vocational Nurse (LVN), California State Board of Vocational Nursing and Psychiatric Technicians, 239637, 08/31/26
- Basic Life Support (BLS), American Heart Association
- Occupational Hearing Conservation Certification (OHC), Council for Accreditation in Occupational Hearing Conservation
Electronicmedicalrecords
- TrueCare
- NextGen
- OMNI
- Point Click Care
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Accomplishments
- Supervised team of 6-10 staff members.
Timeline
Concurrent Review Nurse
Centene Corporation
03.2023 - Current
Lead Dispensing Nurse
Acadia Healthcare
11.2017 - 03.2020
Inpatient Case Manager
Choice Medical Group
02.2016 - 03.2017
Medical Administrator
Medcor
05.2013 - 02.2016
Patient Care Coordinator
Bloomington Health Services
06.2012 - 05.2013
Charge Nurse
Pilgrim Place Health Services
02.2009 - 06.2012
Licensed Vocational Nurse Training (LVN) -
Northwest College
Nightingale College
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