REYNA SALA, RN
Sunrise,FL
Summary
Registered nurse with great critical-thinking skills, communication skills, and compassion with 19 years of case management and utilization review experience.
Overview
20
20
years of professional experience
Work History
Utilization Review Nurse
Humana Healthcare
02.2012 - 01.2024
- Met daily productivity metric goals
- Reduced skilled nursing rehab (SNF) readmission rates to 4%
- Actively participated in task force groups and led new hire training.
- Subject Matter expert (SME) for team
- Passed documentation and Verint audits.
- Maintained compliance with CMS/NCQA/Department guidelines for Pre-authorization, Retrospective Review, Peer to Peer, QIO Appeals, and Medical Necessity Denials (Compliance)
- Delivered passing scores for inter-rater reliability( IRR) testing yearly
- Performed prior authorization review of services requiring notification.
- Submitted cases to staff Physicians for criteria failures and helped solve and facilitate resolutions and approvals.
- Collaborated with healthcare team members to plan, implement, and enhance treatment strategies.
- Strengthened training and nursing knowledge by taking part in continuing education programs and CEU workshops.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
Case Manager
Today’s Options Medicare Advantage
09.2004 - 02.2012
- Telephonic case management for Medicare Advantage PPO and PFFS products.
- Initial Intake and concurrent reviews for Long Term Care policyholders and disease management through several Long-Term Care Policies.
- Managed case load of 50 patients
- Advocating for members to receive most appropriate level of care.
- Coordinating care with discharge planners, physicians, HHA, and DME.
- Health and Wellness education and coaching.
- Disease Management and patient education of CHF, COPD, Diabetes, and CAD.
- Utilization Management of Home Health, Negative Pressure Wound Therapy, SNF-Concurrent review.
- Use of InterQual Criteria.
- Designed, implemented, and trained remote nursing staff on member assessment completion.
- Presented clinical case reviews to peers and supervisors for quality improvement evaluation.
Home Health Registered Nurse Case Manager
Pioneer, Home Health Agency Inc., Miami, FL
07.2004 - 07.2005
- Advised and coached patients progressing from hospitals, rehab facilities and other medical organizations to at-home treatment settings.
- Provided complete care to home health patients, including physical assessments, medication and chronic disease management.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
- Determined and addresses individual home care needs by completing detailed assessments and reviewing documentation.
- Took samples such as blood and urine to complete diagnostic and routine assessment tests.
- Communicated with patients, ensuring that medical information was kept private.
Education
Bachelor of Science - Nursing
Cappella University
Minneapolis, MNAssociate of Science - Nursing
Excelsior University
Albany, NY04.2021
Practical Nursing - Nursing
Miami Lakes Educational Center
Miami Lakes, FL02.2004
Skills
- Utilization Review
- Managed Care
- Microsoft Office Suite
- Accurate and Timely Documentation and Review
- Decision-Making
- EMR / EHR
- Critical Thinking
- Case Management
- Discharge Planning Coordination
- Multidisciplinary team collaboration
- Medicare Guidelines
- Bilingual English and Spanish
Timeline
Utilization Review Nurse
Humana Healthcare
02.2012 - 01.2024
Case Manager
Today’s Options Medicare Advantage
09.2004 - 02.2012
Home Health Registered Nurse Case Manager
Pioneer, Home Health Agency Inc., Miami, FL
07.2004 - 07.2005
Bachelor of Science - Nursing
Cappella University
Associate of Science - Nursing
Excelsior University
Practical Nursing - Nursing
Miami Lakes Educational Center
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