Sandra Ramirez
Santa Teresa
Summary
Analytical and detail-oriented known for effective problem-solving in the Utilization Review process. Experienced in conducting comprehensive patient reviews, managing appeals, and collaborating with multidisciplinary teams.
Overview
11
11
years of professional experience
Work History
UR Specialist
Peak Behavioral Health
Santa Teresa
03.2023 - Current
- Reviews patient records for medical necessity and appropriateness of care.
- Performs concurrent, continued stay, and retrospective reviews.
- Communicates effectively with insurance companies and health maintenance organizations (HMOs) for approval of initial or additional inpatient days for treatment.
- Appeals denials.
- Communicates effectively with co-workers, caseworkers, and nursing staff regarding charting deficiencies and problems/issues identified.
- Coordinates information and findings with the business office to help recognize or resolve possible payment problems.
- Monitors patient length of stay, extensions, and informs clinical and medical staff of issues that may impact length of stay.
Utilization Review Manager
Emergence Health Network
El Paso
12.2019 - 02.2023
- Coordinated, implemented, and managed the Utilization Management at the Alternatives Program to include Prior Authorization, Utilization, and Concurrent reviews for the PHP and IOP programs.
- Completed preauthorization for TMS (Transcranial Magnetic Stimulation) services.
- Reviewed appeals from providers regarding denied requests for services or treatments.
Multisystemic Therapy (MST) Therapist
Emergence Health Network
El Paso
03.2014 - 12.2019
- Served as a team leader to train staff in the MST model.
- Applied the MST model, provided therapy and education to families (parents and youth) in their homes, schools, and probation programs.
- Developed tailored treatment plans based on client assessments and goals.
- Provided crisis interventions as needed, 24/7.
- Attended court hearings to advocate for the youth and their families.
Education
Master of Arts - Sociology
University of Texas
TX05-2010
Bachelor of Arts - Psychology
University of Texas
TX12-2005
Skills
- Utilization management
- Patient assessment
- Insurance authorization
- Healthcare regulations
- Clinical documentation
- Conflict resolution
- Critical thinking
- Leadership skills
Timeline
UR Specialist
Peak Behavioral Health
03.2023 - Current
Utilization Review Manager
Emergence Health Network
12.2019 - 02.2023
Multisystemic Therapy (MST) Therapist
Emergence Health Network
03.2014 - 12.2019
Master of Arts - Sociology
University of Texas
Bachelor of Arts - Psychology
University of Texas
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