Suzanne Rivera
Monroe Township,NJ
Summary
Achieved significant advancements in precertification accuracy and timeliness at EmblemHealth Services, leveraging strong clinical documentation and critical thinking skills. Fostered interdepartmental collaboration and mentored new hires, enhancing workflow coordination and resource utilization. Demonstrated a commitment to HIPAA compliance and continuous professional development. Proactive and goal-oriented professional with excellent time management and problem-solving skills. Known for reliability and adaptability, with swift capacity to learn and apply new skills. Committed to leveraging these qualities to drive team success and contribute to organizational growth.
Overview
19
19
years of professional experience
1
1
year of post-secondary education
1
1
Certification
Work History
Care Manager/Retrospective Precertification Nurse
EmblemHealth Services
10.2020 - 10.2023
- Performed accurate documentation of patient assessments, interventions, and outcomes in compliance with regulatory standards.
- Evaluated patient histories, complaints, and current symptoms.
- Evaluated medical necessity documentation to support the appropriate level of care for patients.
- Mitigated potential delays in service delivery through proactive identification of potential roadblocks within the precertification process.
- Maintained strict adherence to HIPAA regulations by safeguarding confidential patient information during all aspects of the precertification process.
- Contributed extensively to departmental goals through consistent achievement of individual performance benchmarks related to precertification accuracy and timeliness.
- Continuously expanded personal knowledge of industry regulations and updates through ongoing professional development, ensuring accurate and up-to-date expertise in the precertification process.
- Improved team productivity with regular training sessions on new software programs and tools utilized in the precertification process.
- Enhanced interdepartmental collaboration through effective communication with case managers, physicians, and billing departments.
UM Concurrent Reviewer
ANTHEM Health Services
02.2005 - 05.2020
- Assisted in developing strategies to reduce readmission rates by analyzing data from concurrent reviews and collaborating with clinical teams.
- Managed approximately 25-30 cases on a consistent basis with weekly reviews
- Streamlined review processes, resulting in improved efficiency and timely decision-making for patient care.
- Contributed to case management meetings by presenting findings from concurrent reviews, fostering an environment of collaboration among colleagues from various disciplines within the organization.
- Ensured accurate data entry into relevant systems while maintaining strict confidentiality in accordance with HIPAA guidelines.
- Utilized analytical skills to evaluate complex cases, ensuring accurate determinations were made based on medical necessity criteria and standards of care guidelines.
- Mentored new hires, providing guidance and support to help them become effective concurrent reviewers.
- Responded promptly to inquiries from healthcare professionals regarding case updates or additional information needed for timely decision-making on patient care plans.
- Managed a high volume of cases efficiently, prioritizing tasks based on urgency and complexity.
- Participated in quality improvement projects to enhance overall performance within the organization.
- Participated in ongoing professional development opportunities to stay current with industry trends, best practices, and regulatory requirements.
- Developed strong relationships with healthcare providers through consistent collaboration and open communication channels during the review process.
- Enhanced patient care by conducting thorough concurrent reviews and ensuring appropriate utilization of resources.
- Supported the implementation of evidence-based practices by assessing appropriateness of treatment plans during concurrent reviews.
- Evaluated medical guidelines and benefit coverage to determine appropriateness of services.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Performed admission reviews based for medical necessity based upon Interqual specification.
- Facilitated workgroup meetings with medical personnel to find effective solutions to issues.
- Documented treatments delivered, medications and IVs administered, discharge instructions, and follow-up care.
Education
Some College (No Degree) -
Middlesex County College
Edison, NJ 09.1996 - 05.1997
Practical Nursing - Practical Nursing
Middlesex County Vocational School Piscataway
Piscataway, NJ1984
Skills
Utilization Management
- Clinical Documentation
- Medication reviews
- Medical chart review
- Discharge Planning
- Critical Thinking
- Adhere to HIPAA Guidelines
- Decision-Making
- Schedule/Time Management
- Training and mentoring
Certification
CPHM Certified
Languages
English/Spanish
Native or Bilingual
Timeline
Care Manager/Retrospective Precertification Nurse
EmblemHealth Services
10.2020 - 10.2023
UM Concurrent Reviewer
ANTHEM Health Services
02.2005 - 05.2020
Some College (No Degree) -
Middlesex County College
09.1996 - 05.1997
Practical Nursing - Practical Nursing
Middlesex County Vocational School Piscataway
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