Monique Aguirre
RN, PHN, CCM
Summary
Adept at enhancing patient outcomes and ensuring regulatory compliance, with a recent tenure at L. A Care Health Plan honed Quality Improvement and Utilization Review expertise. Leveraging acute care expertise and empathetic patient engagement, I've driven significant improvements in care coordination and patient satisfaction, embodying a results-oriented approach with a blend of hard and soft skills—well-qualified Nurse Consultant with over ten years of Managed Care and Utilization review experience. Critically evaluates documents and develops summaries for quality of care and expedited grievance and appeal deadlines. Detail-oriented team player with strong organizational skills. Ability to handle multiple projects simultaneously with a high degree of accuracy.
Overview
13
13
years of professional experience
1
1
Certification
Work History
Appeals and Grievances – RN, Nurse Specialist
L.A Care Health Plan
04.2024 - Current
- Investigate and resolve member and provider complaints and appeals.
- Provide resolution of complaints in compliance with the Centers for Medicare and Medicaid Services (CMS)
- California Department of Health Care Services (DHCS), Department of Managed Health Care (DMHC), Managed Risk Medical Insurance Board (MBMIB), and National Committee for Quality Assurance (NCQA) regulatory requirements.
- Review pre-service authorizations, concurrent and post-service (retroactive review) for medical necessity, benefit coverage appeals and reconsiderations, and complex provider claim disputes.
- Assisted with departmental audits, ensuring compliance with regulatory requirements and identifying opportunities for improvement.
- Participated in policy development processes within the healthcare organization, influencing changes that improved the overall efficiency of operations.
- Utilization Review- All levels of care
Travel Nurse - Inpatient Case Manager, RN
Medical City Hospital
04.2024 - Current
- CImproved patient outcomes through careful monitoring and thorough documentation of vital signs, medical histories, and treatment plans.
- Maintained excellent time management skills during periods of high patient turnover while consistently delivering compassionate and patient-centered care.
- Utilized strong assessment skills in identifying early warning signs of complications or deterioration in patients'' conditions, allowing for prompt interventions when necessary.
- Collaborated with interdisciplinary healthcare teams to develop and implement individualized care plans tailored to meet patients'' specific needs.
- Documented patient interactions and interventions in EPIC EMR.
- Utilization Review/ InterQual Review
- ICU, PCU, NICU, Mother/Baby, Complex Cardio/ Ortho, Surgical,Trauma
- Implemented care plans for patient treatment after assessing physician medical regimens.
Supervisor of Transition of Care, RN
Blue Shield of CA
07.2023 - 02.2024
- Supervise the day-to-day activities of case management staff, consisting of ten registered nurses and ten coordinators.
- Distribute -Daily case Assignments
- Monitor staff performance, productivity, and Key Performance Indicators (KPIs).
- Developed and implemented desk-level procedures (DLP) to transition care services.
- Lead and Manage Daily team Huddle Agenda, Minutes, and Action Items.
- Attend and Supervise Clinical Coordinator huddle.
- Troubleshoot and manage CM caseloads & Daily assignments
- Demonstrated commitment to the organization's core values, leading by example and fostering a culture of excellence.
- Triaged cases for appeals and grievances, ensuring cases were assigned appropriately.
- Internal nurse audits ten RNs and 10 Coordinators- NCQA guidelines
- Applied strong leadership talents and problem-solving skills to maintain team efficiency and organize workflows.
Continuous Care Nurse
Healing Care Hospice
12.2020 - 10.2021
- Reduced patient anxiety through effective communication and active listening.
- Provided emotional support to patients facing difficult diagnoses or treatment plans, helping them navigate their healthcare journey with confidence.
- Consistently received positive feedback from patients and families for providing exceptional care, compassion, and professionalism during their healthcare experiences.
- Conducted thorough assessments of patients'' physical and emotional well-being to inform care decisions.
- Educated family members on proper caregiving techniques, fostering improved patient outcomes at home.
Senior Nurse, Complex Case Manager
Care 1st/ Blue Shield of California Health Plan
01.2014 - 07.2023
- Led educational workshops for staff members on topics such as Hospice Palliative care, High Risk OB, Community Resources
- Evaluated patient progress against treatment goals regularly, adjusting interventions to promote optimal outcomes.
- Conducted regular quality improvement audits, identifying areas of concern and implementing corrective actions when necessary.
- Participated in interdisciplinary rounds, contributing valuable insights to improve care coordination efforts.
- Improved patient outcomes by developing and implementing evidence-based nursing practices.
- Reduced hospital readmissions by providing thorough patient education on medication management and self-care techniques.
Case Manager, LVN
Charter Palliative Care
01.2013 - 01.2014
- Promoted quality of care through direct patient care by ensuring the transition of care from hospital to home to provide comfort care and symptom management.
- Collaborate with Medical Directors to promote quality and cost-effective outcomes.
- Played a pivotal role in ensuring appropriate care coordination for palliative care management, working closely with the Managed Health plan.
- Complex coordination of care, chronic pain, through inpatient and outpatient levels of care ensure care gaps were addressed to patient satisfaction.
- Transition to Hospice care when appropriate.
Hospice Nurse Case Manager, LVN
Charter Hospice
07.2011 - 01.2013
- Developed strong relationships with patients and families through empathetic listening skills and emotional support during difficult times.
- Educated family members on the hospice process, empowering them to make informed decisions regarding their loved one''s care.
- Collaborated with interdisciplinary healthcare teams to develop comprehensive care plans for hospice patients, leading to improved quality of life.
- Enhanced patient comfort by providing compassionate end-of-life care and support to patients and their families.
- Delivered culturally sensitive care by considering diverse backgrounds when tailoring individualized support strategies for each patient.
Education
Bachelor of Science - Nursing BSN
Azusa Pacific University
Azusa, CA07.2021
Skills
- Discharge Planning
- Quality Improvement
- Health Promotion
- Utilization Reviewer
- Certified Case Manager
- Chronic Disease Management
- Acute care expertise
- InterQual
- Milliman Guidelines
- Advanced Medical Review
- Inpatient Case Manager
- Team Coordination
- Patient care planning
Certification
- Certified Case Manager Until 2029
- California Board of Registered Nursing No. 95263319 Valid until May ‘25
- Texas Registered Nurse No. 1069676 Valid until April ‘25
- Public Health Nurse No. 562805 Valid until May ‘25
- Basic Life Support (BLS), American Heart Association Valid until June ‘26
Languages
Spanish
Timeline
Appeals and Grievances – RN, Nurse Specialist
L.A Care Health Plan
04.2024 - Current
Travel Nurse - Inpatient Case Manager, RN
Medical City Hospital
04.2024 - Current
Supervisor of Transition of Care, RN
Blue Shield of CA
07.2023 - 02.2024
Continuous Care Nurse
Healing Care Hospice
12.2020 - 10.2021
Senior Nurse, Complex Case Manager
Care 1st/ Blue Shield of California Health Plan
01.2014 - 07.2023
Case Manager, LVN
Charter Palliative Care
01.2013 - 01.2014
Hospice Nurse Case Manager, LVN
Charter Hospice
07.2011 - 01.2013
Bachelor of Science - Nursing BSN
Azusa Pacific University
- Certified Case Manager Until 2029
- California Board of Registered Nursing No. 95263319 Valid until May ‘25
- Texas Registered Nurse No. 1069676 Valid until April ‘25
- Public Health Nurse No. 562805 Valid until May ‘25
- Basic Life Support (BLS), American Heart Association Valid until June ‘26
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