Rubylyn Garcia

As Utilization Review Nurse I serve as a clinical expert on Cardiac Surgery/Cardiology work queues and provide coverage to other work queues when needed such as Trauma, Labor and Delivery, Medicine, NICU, Medicare, Cancer & Transplant work queues among others. I ensure correct usage and application of nationally recognized care guidelines/criteria such as the Milliman Care Guidelines (MCG), in order to assess the patient’s appropriateness for Inpatient Stay and Level of Care. My role requires coordination with case managers, medical team, physician advisor, other hospital staff and payors. Specific job activities include the following:

• Completes accurate and timely utilization reviews for assigned work queue, including additional assignment to cover for a team member’s absence.
• Mentors & acts as a team resource to employees who have recently been hired.
• Performs Denial Management appropriately. Completes P2P requests in the amount of time specified by each payor. Level 1,2,3 peer to peer appeal.
• Communicates with Case Manager, Physician Advisor, Medical Team and Payors regarding pended day/denied days and interventions.
• Reviews tests, procedures and consultations for appropriate utilization of resources in a timely manner.
• Collaborates with multidisciplinary teams on developing strategies for improving care quality and controlling costs.
• Communicates and demonstrates good working relationship with payors.
• Ensures appropriate Level of Care and patient status for each patient whether they are applicable for Observation, Extended Recovery, Administrative, Inpatient, Critical Care, Intermediate Care and Med-Surg.
• Provides education to other departments on process improvement projects.
• Leads and promotes best practice in the day to day operations.
• Participates in interviewing applicants who are interested in joining the department.
• Assists Case Manager in Avoidable Days Collection.
• Ownership of Regulatory Compliance as outlined by Centers for Medicare and Medicaid.
• Demonstrates knowledge on sending utilization reviews for Medicaid cases via Qualitrac.
• HINN discussions when necessary.

• Examines available electronic medical records during the pre-admission process to determine appropriate patient status, optimizing correct patient classification and corresponding payer notifications.
• Utilizes nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care.
• Creates initial admission reviews for patients requiring hospital services and provides timely status recommendations to admitting providers in accordance with departmental and clinical guidelines.
• Ensures key regulatory requirements are met as defined by agencies such as the Centers for Medicare and Medicaid.
• Interfaces with the case managers, attending physicians in order to provide the appropriate level of care for patients.

• Under general supervision, provides utilization review and denials management for an assigned patient case load.
• Utilizes nationally recognized care guidelines/criteria to assess the patient’s need for outpatient or inpatient care as well as the appropriate level of care.
• Interfaces with the case managers, medical team, other hospital staff, physician advisors and payers.

The Local Care Coordinator (LCC) supports the implementation of the CareFirst Patient-Centered Medical Home (PCMH) program by working with CareFirst members who are attributed to a Primary Care Physician (PCP) that meet the criteria for Care Coordination. The LCC advocates, guides and intervenes on behalf of her members to ensure successful implementation of the Care Plan while providing Complex Case Management through the duration of the Care Plan. The LCC acts as the primary liaison between the CareFirst program and individual primary care providers (PCPs) and their patients (members).

Essential Functions:

• Established relationships with PCPs in order to ensure continuity of care for clients.
• Served as an extension of the PCPs who participate in the PCMH Program.
• Collaborated with PCPs, clients and sometimes specialist providers in developing and implementing of care plans; Delivered coordinated services for members identified through this CareFirst program.
• Reviewed and managed all Care Plans; coordinated member’s post discharge follow-up for applicable transitions.
• Assisted member in coordination of any additional tests, images and consults with specialists as deemed appropriate by the PCP or Specialist.
• Assessed member's ongoing care needs and progress towards goals throughout the case duration and made revision as needed to address changes in the member's condition, lack of response to the care plan, preference changes, and transitions in care settings.
• Coordinated plan of care with the provider with goals of member stabilization, decreased admissions and medication management.
• Connected with each member every week telephonically or in-person.
• Provided education about mental health issues and available resources to clients and their families.
• Coordinated and monitored client's access to needed medical, social, educational, and other services.
• Conducted assessments of clients' needs, abilities, and preferences to determine eligibility for services.