Varoneca User

Handles prior authorization for commercial, Medi-Cal, and Medicare members using guidelines including MCG and Medicare guidelines. Reviews denials and modifications with medical directors and coordinates care for transplant, ESRD, and oncology members.

Instructs LVN students in clinical hospital skills, oversees clinical skills practice and competence sign-off, and teaches classroom theory and assessments for hospital rotations.

Reviews claims appeals, reconsiderations, and PDR cases for inpatient and outpatient services. Extracts clinical documentation and applies benefit, medical necessity, and regulatory criteria to determine case outcomes.

Performs reviews of inpatients with complex medical and social problems, generates referrals to ancillary providers, and coordinates care activities with patients, families, and healthcare teams.

Served as lead inpatient review nurse, reviewing complex inpatient cases, participating in multidisciplinary conferences, and overseeing discharge planning and prior authorizations using Milliman and CMS guidelines.

Managed case management and referral processes for members, utilizing InterQual and Milliman guidelines for prior authorization reviews and coordinating with hospital case management and various healthcare providers.

Pilot nurse leader for afterhours program, trained new employees in concurrent review and utilization management, and managed acute care episodes including discharge planning and authorization oversight.

Performed inpatient reviews for complex cases, generated referrals, and coordinated care activities with patients and healthcare teams, including multidisciplinary conferences and HEDIS reporting.

Independent contractor for multiple medical groups' afterhours call line, responsible for case management and referral processes, and coordinating with hospital case management and various healthcare providers.

Provided complete patient care to antepartum, labor and delivery, and postpartum patients, as well as newborns.

Supervised medical assistants and front/back office staff, coordinated nursing services including prenatal care, and managed referral processes, immunization programs, and insurance verification for PPO and HMO groups.

Supervised home visitors and childcare center staff, managed health and nutritional services for community members, and oversaw immunization compliance and screening management.

Provided total patient care for OB/GYN patients including labor and delivery, postpartum care, and cesarean section assistance, and managed high-risk antepartum patients with various conditions.

Provided total care for patients pre and post open-heart surgery, COPD, renal dialysis, organ transplant, and other complex conditions, including wound care, IV infusions, and diabetic management.

Assisted with patient triage, registration, IV infusions, Foley catheter, chest tubes, lab draws, wound and burn care, and pediatric emergencies.

Graduated with a Bachelor of Arts in Psychology from California Southern University in 2019.

Completed the LVN Program at Citrus Community College.