Ronan Garcia, RN
Dallas,Texas
Summary
Dedicated and adaptable professional with a proactive attitude and the ability to learn quickly. Strong work ethic and effective communication skills. Eager to contribute to a dynamic team and support organizational goals.
Overview
9
9
years of professional experience
Work History
Utilization Management Nurse (Nurse Medical Manage
Carelon Global Solutions (Elevance Health)
07.2023 - 05.2024
- Anthem National Account Inpatient Account, Chronic Care Management (ANA IPA, CCM) is responsible for managing inpatient and observation services in order to determine if a patient will remain at a healthcare facility or be discharged. By reviewing medical records and assessing medical review standards, a Concurrent Review Nurse is able to determine the overall health of the patient and evaluate treatment needs.
- Responsible for managing inpatient and observation services in order to determine if a patient will remain at a healthcare facility or be discharged.
- By reviewing medical records and assessing medical review standards, a Concurrent Review Nurse is able to determine the overall health of the patient and evaluate treatment needs.
- Managing hospital stays: Reviewing medical records at admission and regularly throughout a patient's stay until they are discharged.
- Identifying discharge and continuing care plans: Identifying a discharge plan early in a patient's stay and assessing it during their stay.
- Identifying quality of care concerns: Identifying and referring potential quality of care concerns and patient safety events for additional review.
- Managing healthcare resources: Managing the inpatient utilization of healthcare resources to ensure that the coordination and continuity of care result in optimal patient outcomes.
- Collaborating with others: Communicating and collaborating with case managers or utilization review nurses to complete an authorization or obtain missing information.
- Maintaining records: Maintaining accurate records of all patient-related interactions.
Utilization Management Nurse (Nurse Medical Management I)
Carelon Global Solutions Philippines, Inc. (Elevance Health)
11.2022 - 07.2023
- Post Service Clinical Claims Review (PSCCR) is done to determine the medical necessity and/or level of care for services that had been rendered without obtaining pre-service authorization. Only qualified licensed, clinical Registered Nurse (RN) staff are utilized to perform post-service reviews.
- Only qualified licensed, clinical Registered Nurse (RN) staff are utilized to perform post-service reviews
- The PSCCR RN reviews the relevant medical record information in conjunction with the claim as applicable including but not limited to: diagnoses, medical treatment needs, and any social/environmental factors that impacted the member’s medical condition, and makes a determination of medical necessity, length of stay, level of care, etc., using Anthem Medicaid-approved Medical Policies, adopted Clinical and Review guidelines
- Services approved are documented in the claims system and routed to the Operations queue for processing.
- Services rendered that do not meet criteria for medical necessity are sent to an Anthem Medicaid PCR using the Anthem Care Management Platform (ACMP) Medical Management system
- The FileNet document control number is included along with documentation of the review of the service(s) rendered in accordance with the PCR referral process
- The PCR has sufficient expertise to evaluate the specific clinical issues involved in the healthcare services requested by the provider.
- The PCR documents approval, modification, or denial decision in ACMP and tasks the case to the PSCCR associate.
- The PSCCR associate documents the decision in ACMP and Mainframe system and routes the determination to the Operations queue for processing (i.e., for payment, partial payment, or denial).
Staff Nurse
Jose R Reyes Memorial Medical Center
05.2022 - 10.2022
- Assesses the needs of the patient by establishing a professional and therapeutic relationship with the family and patient; obtaining accurate nursing history and performing an initial physical examination; and correlating/utilizing normal and abnormal findings to determine the plan of care
- Managed patients across the lifespan with acute and chronic conditions
- Given pharmacological and non-pharmacological nursing interventions without complaints received
- Prioritizes health needs and problems appropriately
- Implements therapeutic plan of care such as providing and maintaining safety and comfort measures; carrying out doctor’s orders; administering the prescribed medications; monitoring the response of the patient to the prescribed medication, therapeutic order, and diet regimen
- Facilitates referral of patients to other services/diagnostic and laboratory exams the soonest possible time
- Ensures that all services are updated with the current health management of the patient
- Facilitates laboratory/diagnostics and scheduling of the procedure of the patients
- Attends to emergency resuscitative measures as needed such as operating life-saving monitors and equipment; assisting in emergency/invasive procedures; providing relevant health teaching to patients and relatives; providing psychosocial, emotional, and spiritual support respecting their cultural beliefs and values
- Refers significant findings appropriately by collaborating with other members of the health team and receiving/handing-over patients accordingly
- Performs quality nursing care (e.g
- Endorsement, assessment, medication administration, nursing procedures and treatment, nutrition and elimination, health teachings, psychosocial/spiritual care, referral to appropriate services, rehabilitation and prevention of complications, and evaluation of care) to assigned patients
- Performs nursing care activities to newly-admitted patients within two hours upon arrival at designated ward within the prescribed time
- Performs hospital infection control measures/guidelines
- Performs and facilitates peri-operative needs of patients for emergency and elective operation/procedure
- Provides an efficient, effective, and timely delivery of care and safe workplace environment.
Utilization Review Nurse
EXL Philippines (Zurich Insurance)
05.2019 - 07.2021
- Working as part of an insurance claims that reviews medical documents from the United States
- Perform frequent case reviews, check medical records for worker’s compensation
- Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay
- We also assist with determining whether a treatment meets the criteria for reimbursement by the insurance plan
- They are involved in pre-certification, which determines whether a recommended procedure, medication, or therapy is appropriate for an individual according to the guidelines of their insurance plan
- Gather medical data to evaluate the necessity of medical treatment and functional capabilities
- Evaluates the necessity, appropriateness, and efficiency of medical services and procedures provided.
Registered Nurse (Emergency Room Senior Staff Nurse)
Mary Johnston Hospital
07.2015 - 04.2019
- Rendering compassionate care to critical patients suffering from injuries or life-threatening conditions and assessing patient conditions, rendering care, and with general knowledge for patients from various cases such as surgical, medical, OB, Gynecology, Urology, Neurology, Trauma, Oncology, Renal, Hematology, Cardiology, Orthopedics, Pediatrics, Psych, etc.
- Performed screening and assessment of patients.
- Taking vital signs, medical history information, and answering queries.
- Managed patients across the lifespan with acute and chronic conditions.
- Given pharmacological and non-pharmacological nursing interventions without complaints received.
Education
Bachelor of Science in Nursing -
College of Nursing, Universidad De Manila
04-2014
Skills
- Skilled at working with clients of all age groups
- A team player who works well with others
- Excellent communication skills
- Proficient in English language (communication and writing skills)
- Has knowledge in operating various computer applications, healthcare software of the hospital and medical insurance management programs
- Managed life support equipment and IV administration of fluids and medications
- Physical endurance (working in long hours with loads of work and patients)
- Observe behavior, symptoms and report changes to physician
- Monitored telemetry and responded to codes
- Assisted physicians with medical or surgical procedures
- Actively participated in numerous code and emergency encounters providing compressions, timer, assist with intubations, giving of medications
- Educate families about conditions, and general health trends
- Assesses patient's clinical need against established guidelines and/or standards to ensure that the level of care and length of stay of the patient are medically appropriate for inpatient stay
- Gather medical data to evaluate the necessity of medical treatment and functional capabilities
- Evaluates the necessity, appropriateness and efficiency of medical services and procedures provided
- Managing inpatient and observation services in order to determine if a patient will remain at a healthcare facility or be discharged
- Managing hospital stays: Reviewing medical records at admission and regularly throughout a patient's stay until they are discharged
Timeline
Utilization Management Nurse (Nurse Medical Manage
Carelon Global Solutions (Elevance Health)
07.2023 - 05.2024
Utilization Management Nurse (Nurse Medical Management I)
Carelon Global Solutions Philippines, Inc. (Elevance Health)
11.2022 - 07.2023
Staff Nurse
Jose R Reyes Memorial Medical Center
05.2022 - 10.2022
Utilization Review Nurse
EXL Philippines (Zurich Insurance)
05.2019 - 07.2021
Registered Nurse (Emergency Room Senior Staff Nurse)
Mary Johnston Hospital
07.2015 - 04.2019
Bachelor of Science in Nursing -
College of Nursing, Universidad De Manila
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