YESENIA SANCHEZ
North Hollywood,CA
Summary
Skilled Licensed Vocational Nurse leverages critical thinking, analysis and medical knowledge to deliver superior care in high-pace and high-pressure environments.
Overview
10
10
years of professional experience
1
1
Certification
Work History
Quality Assurance Nurse
Millennium Home Health, Inc.
Valenica, CA
03.2024 - Current
- Performed ongoing audits of patient charts to ensure compliance with relevant laws and regulations.
- Conducted audits of denied claims and authorization requests to determine the cause of denial.
- Reviewed policies to determine appropriate levels of coverage and assist with approval or denial decisions.
- Adept knowledge reviewing Medicare criteria such as Centers for Medicare & Medicaid Services (CMS) and Health Plan guidelines such as Anthem, Cigna, Health Net and United Healthcare.
- Collaborated with other departments to ensure timely processing of denials.
- Conducted comprehensive assessments of patient care to ensure quality standards were being met.
- Maintained detailed records of all claims processed, including status updates and changes.
- Ensured that medical staff was adhering to established protocols and procedures related to patient safety and quality assurance.
- Participated in interdisciplinary meetings focused on developing strategies for improving the delivery of safe, high-quality care.
- Generated reports detailing the number of denied claims received each month.
UM LVN Nurse Reviewer
Optum Medical Group
Arcadia, California
10.2016 - 08.2023
- Responsible for processing all referrals within appropriate turnaround time for all urgent, routine, senior and commercial line of business.
- Review precertification requests for medical necessary based on the Medicare or Health Plans medical guidelines for requested service/procedure.
- Proficient knowledge working with Centers for Medicare & Medicaid Services (CMS), National Coverage Determination (NCD), Local Coverage Determination (LCD), Articles, Medi-Cal, MCG, UpToDate and different Health Plan guidelines.
- Accurately packaging all authorizations I am unable to adjudicate and referring those that require additional expertise to the Medical Director.
- Responsible for presenting, preparing, and submitting all recommendations for denial to the Physician Reviewer and attaching all pertaining documentation and guidelines.
- Ability to promote quality care in the most cost-effective medical outcome.
- Preventing hospitalizations when possible and appropriate and decreasing prolong lengths of hospital stay.
- Assisting with the specialty review queue for all denials, redirects to primary network and benefit carve outs as needed.
- Establish effective rapport with other employees, physicians, patients, and management.
- Taking calls from patients, health plans or doctor’s office with questions on a referral and or processing time.
UM Nurse Reviewer
Regal Medical Group
Northridge, California
02.2015 - 08.2016
- Assessed patient medical records to determine the appropriateness of requested services and procedures.
- Applied medical criteria and clinical judgement to researched cases to evaluate and establish determinations.
- Ability to support the Medical Director to promptly, efficiently and accurately execute all aspects of the referral process.
- Knowledge in promoting quality, cost effective medical care through strict adherence to all UM policies and procedures.
- Responsible for the daily review and processing of referral authorizations in accordance to turnaround time (TAT) standards set by Health Plan requirements.
- Remained up-to-date on various benefit plans, medical policies and state-specific clinical guidelines or criteria.
- Generate denial letters for providers and members using the appropriate denial letter based on type of denial and using language at the layperson level for understanding.
- Redirecting requests from non-contracted providers to utilize in network service providers.
- Interpreted benefit plans, medical necessity criteria, policy language, and state regulations for proper utilization of services covered under a health plan.
- Maintained accurate documentation of all prior authorization activities in accordance with established policies and procedures.
Licensed Vocational Nurse
Choice Home Health
Sherman Oaks, California
03.2014 - 02.2015
- Provided nursing care and services that is in accordance with Agency patient care and general medical policies.
- Nursing care includes physical, emotional support and patient teaching.
- Assessed, monitored and documented patient progress, symptoms and vital signs on each visit.
- Educated clients and their families on the safe treatment of injuries, illnesses and conditions.
- Provided patients with the knowledge and assistance to learn appropriate self-care techniques.
- Recognized and reported symptoms that indicate changes in the condition of the patient to the Case Manager.
- Administered medications and treatments that are assigned by the physician listed on the plan of care, and recorded these with accuracy and completeness.
- Worked on additional projects as assigned or needed.
Education
Vocational Nursing -
Casa Loma College
01.2013
Some College (No Degree) - General Education Courses/Nursing Pre-requisites
Glendale Community College
Glendale, CASkills
- Bilingual (English and Spanish)
- Proficient in Microsoft Word, Excel, Outlook, PowerPoint and OneNote
- High Achiever
- Ability to work in a multi-task, fast pace, high stress environment
- Strong clinical judgment
- Highly organized and strong attention to detail
Certification
- Licensed Vocational Nurse
- Intravenous and blood withdrawal Certified
- CPR and BLS Certified
Timeline
Quality Assurance Nurse
Millennium Home Health, Inc.
03.2024 - Current
UM LVN Nurse Reviewer
Optum Medical Group
10.2016 - 08.2023
UM Nurse Reviewer
Regal Medical Group
02.2015 - 08.2016
Licensed Vocational Nurse
Choice Home Health
03.2014 - 02.2015
Vocational Nursing -
Casa Loma College
Some College (No Degree) - General Education Courses/Nursing Pre-requisites
Glendale Community College
Similar Profiles
Muna JamaMuna Jama
LPN at New Millennium Home HealthLPN at New Millennium Home Health
Bella DavydovBella Davydov
HHA at New Millennium Home HealthHHA at New Millennium Home Health
Whitney StoutWhitney Stout
Supervisor at Saint Francis Health SystemSupervisor at Saint Francis Health System
Maui HolcombMaui Holcomb
Owner/Supervising Sound Editor at Ear Candy SoundOwner/Supervising Sound Editor at Ear Candy Sound
Juan HernandezJuan Hernandez
Shipping and Receiving Clerk at Ordway Sign SupplyShipping and Receiving Clerk at Ordway Sign Supply