Samantha D Pavon
Los Angeles,CA
Summary
Compassionate Nurse Case Manager offering 13 + years of experience working with patients and families to facilitate smooth transitions following discharge from medical facilities. Committed to working collaboratively with health plan, leadership and department coordinators to achieve highest quality of patient satisfaction. Well-versed in developing individualized care plans and advocating patient welfare. Organized and dependable candidate successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Medical review knowledge with different lines of business for prior authorization.
Overview
15
15
years of professional experience
Work History
LVN Case Manager/Prior authorization
OrthoNet LLC/OPTUM
09.2013 - 06.2023
- Absorbed by OPTUM in 2021
- GEHA and Humana Prior Authorizations for Medicare and commercial ( Spine/Arthroscopic/Podiatry cases)
- United Health Medicare and Retirement plans - musculoskeletal cases / spinal cord stimulator
- Pacific care contract utilization review
- Medicare And Retirement United Health HMO/PPO plan
- Directly responsible for utilization, supervision, instruction, examination of medical care of managed members
- Management of expedited case request - 72 hour TAT
- Performed admission reviews based for medical necessity based upon line of business, POS specification.
- Submitted cases to medical directors for criteria failures and helped facilitate resolutions and approvals.
- Meeting TAT based in line of business
- Participation of training in NCQA and URAC Regulatory Compliance, Confidentiality, Conflict of Interest, HIPAA
- Devise or identify solutions for irregular requests and issues.
- Facilitated workgroup meetings with OCM committee to find effective solutions to issues.
- Educated family members and caregivers on patient authorization outcome on expedited case after verify identity of patient or caretaker to be compliant with HIPPA regulations.
- Advocated for and strived to protect health, safety and rights of patient.
- Updating decisions after approvals have come back from MD/set up P2P
- Peer Coverage when others are out on PTO
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Performed prior authorization review of services requiring notification.
- Performed admission reviews based for medical necessity based upon line of business specification.
- Supervised and maintained all utilization review documentation through EZcap, EZCompanion, MaxxVault programs, KEYKAP, HSR, DOC360, InterQual
Case Management Coordinator
Gentle Care
03.2013 - 09.2013
- Requested authorization for PT and Home Health visits with Kaiser or private pay
- Home health visits – vital check
- Went with PT on some visits for translations English/Spanish
- Wound Care
- Intake of patient
- Assigned nurses on cases / scheduling
- Streamlined, standardized and implemented case management processes and techniques to maximize revenue cycle.
- Leveraged case management tools and conflict management techniques to help interdisciplinary teams achieve optimal outcomes.
- Assisted patients with dressing, grooming and feeding needs, helping to overcome and adapt to mobility restrictions.
- Traveled to clients' homes to complete healthcare services and promote continuity of care.
- Provided mobility assistance such as walking and regular exercising.
- Completed entries in log books, journals and care plans to accurately document and report patient progress.
- Assisted disabled clients to support independence and well-being.
- Offered patients and families emotional support and instruction in preparing healthy meals, independent living and adaptation to disability or illness.
- Developed rapport to create safe and trusting environment for care.
- Reported unusual or urgent circumstances in patients' condition or environment immediately to nurse supervisor.
- Helped clients with managed home care, ensuring efficacy of care by monitoring health status.
- Documented vital statistics and coordinated with health care providers.
- Supported families through difficult times by offering emotional support and education on important care tasks.
Telephonic Nurse Case Manager
MaxiMed IPA /Edwards IPA
02.2011 - 01.2013
- (left because they closed)
- Case Management for patient under care of IPA – ie
- DM patients, Cancer Pt, frequent flyer
- Ordering of medications
- Review of case files
- UM/QI management
- Coordination of care with the PCP, Specialist, patient and or family members
- Working with Health Plans – Care 1st, Health Net, Blue Shield Commercial, Blue Shield 65+
- CPT/ICD 9 codes
- Coordination of care
- Authorization Review
- CPT/ICD 9 codes
- Coordination w/ Health Plan
- Covered for others in concurrent review Assisting Hands (per diem)
- Evaluated patients referred for case management to determine physical, mental, financial and psychosocial status by utilizing comprehensive, standardized criteria to identify existing and potential needs.
- Screened medical records and information for necessity and appropriateness and referred for physician review cases not meeting medical criteria.
- Collaborated with other health care professionals regarding plan of care and variances in plan implementation to achieve outcomes.
- Collected and inputted case data in managed care system and timely and accurately generated required correspondence and review notification for management.
- Assessed current treatment plan to identify barriers, clarify or determine realistic goals and objectives and seek potential alternatives.
- Worked with medical teams, patients and families to implement effective treatment plans.
- Documented case notes daily and coordinated follow-up for seamless case management.
- Organized clinical documentation, treatment plans, and referrals.
- Coordinated program referrals for community-based resources.
- Coordinated individualized discharge plans to manage safe transition back into community and home environments.
- Provided ongoing counseling to help patients deal with conditions and processes
- Updated treatment plans on monthly basis with latest intervention strategies and progress notes.
- Preserved and prepared reports and treatment records.
- Quickly learned new skills and applied them to daily tasks, improving efficiency and productivity.
- Carried out day-day-day duties accurately and efficiently.
- Demonstrated respect, friendliness and willingness to help wherever needed.
Private Duty
Hospice Care
06.2009 - 06.2010
- Cancer patient fighting cancer for 15+ years with slight dementia
- Assisted in medication administration
- Assisted to the commode, bathing, clothing
- Assisted family in grieving process
- Feedings
- Hospice Care
LVN Student Nurse
Club House
06.2009 - 07.2009
- Spent time with patients with bipolar disorder, schizophrenia, manic depressive, multiple personalities and much more
- Provided direct quality care to patients by monitoring, recording and evaluating psychiatric conditions.
- Quickly learned new skills and applied them to daily tasks, improving efficiency and productivity.
- Carried out day-day-day duties accurately and efficiently.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Performed duties in accordance with applicable standards, policies and regulatory guidelines to promote safe working environment.
- Maintained energy and enthusiasm in fast-paced environment.
LVN Student Nurse
Coast Medical Center
03.2008 - 05.2008
- Med Surg, I&O ICU, Mental Health Unit, ER, Pre-Op before a cataracts surgery, Observed in Endoduadinumendoscopy, Colonoscopy
- Participated in clinical training, seminars and other educational offerings to develop knowledge and skill levels.
- Recognized and reported observations, patient behaviors and other indicators outside normal parameters or directions given by LPN.
- Demonstrated skills and abilities within scope of LPN practice and in accordance with competencies and procedures.
- Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.
- Reviewed patient history to verify conditions and current medications.
- Documented patient vitals, behaviors and conditions to communicate concerns to supervising nurse.
- Responded to patient requests with appropriate clinical and personal assistance.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
- Helped patients complete bathing, dressing and eating.
LVN Student Nurse
Lake Forest Nursing Home
- Worked alongside experienced nursing professionals to learn new procedures.
- Administered close patient care, checked vital signs and monitored telemetry.
- Assisted patients with personal hygiene requirements and monitored conditions to update nursing staff.
- Built rapport with patients and members of patients' support systems.
- Administered medications via oral, intramuscular injections and monitored responses.
- Cared for each patient according to care plan and physicians' instructions.
- Monitored each patient to meet appropriate care and document status changes.
- Changed out and monitored bandages, catheters and IVs.
- Updated patient charts with data such as medications to keep records current and support accurate treatments.
- Collaborated with nurse preceptors and other medical staff to achieve quality patient outcome goals.
- Researched different diagnoses to become familiar with presentation and treatment protocols.
- Completed medical facility experience while under supervision of qualified staff.
LVN Student Nurse
Sunbridge Care and Rehab
- Assessed patients' temperature, pulse and blood pressure and recorded in electronic medical records.
- Documented patient vitals, behaviors and conditions to communicate concerns to supervising teams.
- Protected patients and healthcare team members from infection by sterilizing equipment and reusable supplies.
- Helped long-term care residents with bathing, dressing, feeding and other daily living activities.
- Managed patient care through closely monitoring respiration, blood pressure and blood glucose levels.
- Documented accurate and complete patient information to address patient problems and expected outcomes.
- Monitored, tracked and conveyed important patient information to healthcare staff to help optimize treatment planning and care delivery.
- Comforted and counseled patients and families throughout care process.
- Delivered updates in patient status to charge nurse, recording changes in medical records.
- Responded to patient requests with appropriate clinical and personal assistance.
- Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
LVN Student Nurse
California Hospital
- Managed patient in the OB/GYN, Labor and Delivery, Postpartum, Antepartum, NICU
- Recognized and reported observations, patient behaviors and other indicators outside normal parameters or directions given by LPN.
- Assisted translation at times during delivery
- medical management
- vital sign check
- Used initiative in carrying out recurring tasks within scope of practice and established standards of care.
- Baby heart beat monitor
LVN Student Nurse
Tustin Hospital
- Pediatrics, cleaned tracheostomy, G-Tubes
- Bristol Park, –child wellness checks, immunizations
- Demonstrated skills and abilities within scope of LPN practice and in accordance with competencies and procedures.
- Helped young patients feel comfortable with procedures and immunizations.
- Cultivated rapport with patients and caregivers, utilizing proactive communication with parents and children.
- Provided educational support to patients and families to inform them of procedures.
- Provided bedside care and treatment for patients in Pediatric/Surgical units.
- Educated family members and caregivers on patient care instructions.
- Evaluated patient histories, complaints and current symptoms.
- Advocated for and strived to protect health, safety and rights of patient.
- Administered medications and treatment to patients and monitored responses while working with healthcare teams to adjust care plans.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Offered exceptional care and support to individuals recovering from acute incidents and dealing with chronic conditions.
License Vocational Nurse
Pacific College
09.2009
- VN251913
- Clinical Sights for internship
California State University
08.2005
- General Education Classes - specialized interest in phycology classes
Education
Bachelor of Science - Health Administration
Capella University
Minneapolis, MN2025
License Vocational Nurse - Nursing
Pacific College
Costa Mesa, CA10.2009
Skills
- Clinical documentation
- Communication skills
- Organized
- Supporting Daily Living Needs
- Patient Needs Assessment
- Work Planning and Coordination
- Emotional Support
- Management Team Support
- Sterilize Equipment
- Care Planning and Modifications
Timeline
LVN Case Manager/Prior authorization
OrthoNet LLC/OPTUM
09.2013 - 06.2023
Case Management Coordinator
Gentle Care
03.2013 - 09.2013
Telephonic Nurse Case Manager
MaxiMed IPA /Edwards IPA
02.2011 - 01.2013
License Vocational Nurse
Pacific College
09.2009
LVN Student Nurse
Club House
06.2009 - 07.2009
Private Duty
Hospice Care
06.2009 - 06.2010
LVN Student Nurse
Coast Medical Center
03.2008 - 05.2008
California State University
08.2005
LVN Student Nurse
Lake Forest Nursing Home
LVN Student Nurse
Sunbridge Care and Rehab
LVN Student Nurse
California Hospital
LVN Student Nurse
Tustin Hospital
Bachelor of Science - Health Administration
Capella University
License Vocational Nurse - Nursing
Pacific College
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