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Click here or scroll down to respond to this candidateCandidate's Name LVNEXPERIENCESuperior Health PlanProgram CoordinatorAug 2023-July 2024Verify eligibility. Verify provider is in network. Review proper paperwork is in place.And information meets criteria. Medicare and MedicaidNotify member with correct letter. Notify provider by fax.Using TrueCare, Amysis and Provider contact.Gonzaba MedicalMarch 2020-July 2023Referral NurseProcess referrals for power wheelchairs, prosthetics, and all medical equipment. For all 8 GMG clinics. Verify insurance. Review all orders with correct providers (in network), CPT and HCSPC Codes, and MD signature. Reenter with corrections into system and forward to PCP for signature.Process approved referral, notifying patient and sending approval letter.If request does not meet Medicare guidelines prepare for Medical Review. Obtain clinical, labs, or radiology.Fax approvals to provider with patient demographics and appropriate clinical.Molina HealthCare- Letter TeamJune 2015 March 2020RU department.Denial and Approval Letter Team for Marketplace, Medicare, and Medicaid. Pick out an appropriate letter templet.Proof letters for any needed corrections.Long Term CareHumana, San Antonio-Authorization nurseJune 2010 - June 2015Process provider Auth requests for Private insurance and MedicareUsing InterQual if request does not meet guidelines, prepare for Medical Review: obtain clinical from specialists, labs, or radiology.Including processing denials with medical director instructionProcessing approval and denial letters.Set up peer to peer.Community First Health Plan Case ManagerJuly 2005 - June 2010Process referrals, responsible for special needs and diabetic membersOutreach to members to check on their status and needs. Medication, doctor appointments, follow ups, etc.Identify patients that may be eligible for SSI. Notifying patients of patients, they may be eligible for SSI. Explain SSI.Arrange social worker to patient to help with SSI paperwork. Follow up with parents.South Texas Blood and Tissue Center- Apheresis Nurse2000-2005Processed possible platelet donors. Venipuncture.Attach to automated machine to collect platelets.Care of donors before, during and after automated donation.Assess donors for any reactions.Prepare product for the lab.EDUCATIONSAISD Vocation School of Nursing, San Antonio, Tx.LVN LicenseSchool Name, Golden West College CANursingSkills:Medicare, Star, Star-Plus, Medicaid, MarketplaceMicrosoft. Word, Excel. CCA, CMS, Athena, EZCAP, AvailityMilliman, InterQual |
