Valarie Rodriguez
San Antonio,TX
Summary
Results-oriented and self-motivated professional with 13 years of experience as a registered nurse in a hospital setting as well as a utilization management position. Proven track record success in remote work environments, showcasing strong communication and collaboration skills. Adapt at leveraging technology to enhance productivity and deliver high-quality results.
Overview
13
13
years of professional experience
Work History
Registered Nurse II
Methodist Hospital
01.2024 - Current
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Educated patient/family on chronic disease management and post treatment care, utilizing clinical knowledge and resources to provide clear and accessible health information, leading to a percentage of improvement in patient adherence to treatment plans.
Prior Authorization Nurse/Utilization Management Nurse
Superior Health Plan
04.2023 - 12.2023
- Enhanced patient care by assessing insurance coverage and obtaining prior authorization for medical procedures.
- Utilize decision-making and critical thinking skills in a review and determination of coverage for medically necessary health care services.
- Obtain clinical information to apply the appropriate clinical criteria, policy and procedures, InterQual and clinical judgment to determine coverage.
- Refer case to review physician when treatment request does not meet necessity per guidelines, or when guidelines are not available.
- Knowledge of ICD 10 codes and CPT codes.
- Assisted in maintaining compliance with changing regulations and policies by staying up-to-date on industry trends and best practices.
Prior Authorization Nurse
WellMed
11.2022 - 03.2023
- Performed utilization review activities, including pre-certification, concurrent, and retrospective reviews according to guidelines
- Determined medical necessity of each request by applying appropriate medical criteria to first-level reviews and utilizing approved evidence-based guidelines/criteria
- Utilized decision-making and critical-thinking skills in review and determination of coverage for medically necessary health care services
- Refer case for review physician when treatment request does not meet necessity per guidelines.
Nurse Injector
Hidden Oasis Med Spa
07.2022 - 09.2022
- Ensured proper safety precautions were taken and documented in the patient's medical record
- Performed skin analysis and evaluation on clients
- Administered injectable treatments for facial wrinkles and using dermal fillers such as Restylane, Juvederm, Voluma, Botox, and other well-known products
- Developed a specific treatment plan for clients and an ongoing follow-up.
Prior Authorization Nurse and Care Manager II
Superior Health Plan
07.2016 - 07.2022
- Utilize assessment skills and discretionary judgment to develop a plan of care based on assessment, goals, and interventions designed to meet member's needs and promote desired outcomes
- Coordinate services with Primary Care Physicians, specialists, medical providers, and non-medical staff as necessary to meet the complete medical needs of clients
- Monitor referrals made to community-based organizations, medical care, and other services to support the members' overall care management plan
- Enter and maintain assessments, authorizations, and pertinent clinical information into various medical management systems
- Knowledge of ICD 10 codes and CPT codes.
- Obtain clinical information to apply the appropriate clinical criteria, policy and procedures, InterQual and clinical judgment to determine coverage.
- Refer case to review physician when treatment request does not meet necessity per guidelines, or when guidelines are not available.
Registered Nurse II
Methodist Hospital
10.2011 - 07.2016
- Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.
- Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.
- Skillfully managed challenging patient situations using de-escalation techniques, crisis intervention strategies, and therapeutic communication skills.
- Educated patient/family on chronic disease management and post treatment care, utilizing clinical knowledge and resources to provide clear and accessible health information, leading to a percentage of improvement in patient adherence to treatment plans.
Education
Associate Degree in Nursing - Registered Nurse
San Antonio College
San Antonio, TX08.2011
Skills
- Knowledge of Medicare/Medicaid
- Managed care experience
- Attention To Detail
- InterQual
- Chronic Patient Care
- Organization and Multitasking
- Problem Solving
- Clinical judgment
- Compassion and Empathy
- Discharge Planning
- Microsoft Office
- Referral Coordination
Timeline
Registered Nurse II
Methodist Hospital
01.2024 - Current
Prior Authorization Nurse/Utilization Management Nurse
Superior Health Plan
04.2023 - 12.2023
Prior Authorization Nurse
WellMed
11.2022 - 03.2023
Nurse Injector
Hidden Oasis Med Spa
07.2022 - 09.2022
Prior Authorization Nurse and Care Manager II
Superior Health Plan
07.2016 - 07.2022
Registered Nurse II
Methodist Hospital
10.2011 - 07.2016
Associate Degree in Nursing - Registered Nurse
San Antonio College
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