Medical Management

Licedia Zapata

Email: qwlfhc@r.postjobfree.com

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***** ** **** **** ***. F, Miami, FL 33185 305-***-****

Qualifications

Able to handle priority situation, maintain a professional manner at all times. Knowledge of Forensic Case Management, Mental Health, Substance Abuse, and Geriatric Care.

Professional Experience

Case Manager I 2008 – Present

Fellowship House Psycho-Social Rehabilitation Center, Inc. Miami, FL.

• Provide individualized case management services including intervention, assistance in accessing public benefits; information and referral regarding access to health, mental health and other social service

• Develop individualized treatment plans and monitor progress in achieving goals

• Monitor member compliance with substance abuse recommendation, and develop alternative treatment and /or residential plan, if necessary

• Coordinate with court liaisons, judges and probation officers each members psychosocial rehabilitation and daily functioning

• Coordinate with psychiatrists in order for member to have monthly medication supply.

• Identify member’s needs and assist by linking the member to appropriate services

• Meet productivity requirements as established by the Agency and submit required documentation in the expected timely manner

Home Care Aide Supervisor 2007 – 2008

Miami-Dade County Department of Human Services for

Elderly, Disability & Veterans Service Division, Miami, FL

• Supervised 12 Home Care Aides ensuring their job duties are performed correctly and in a timely manner

• Review time sheets for all clients and ensured accuracy for State funded clients before submission to the Data Entry Specialist

• Performed home visits at least once a year to update all documents required by State and Federal guidelines

• Assist in the preparation of accident and incident reports

• Monitor staff performance to assure client’s services are provided correctly

• Conduct individual performance conferences, completes evaluation, provides staff with a full day schedule to service the clients

• Maintained full communication with the client’s and their family member’s concerning any complaints

• Received and resolved clients’ complaints on a daily basis

Social Worker I – 2006 - 2007

Miami-Dade County Adult Day Care, Miami, FL

• Performed yearly assessment to geriatric clients who’s mobility was limited

• Evaluate quarterly clients’ care plans to assure their emotional and social wellbeing for their participation in all daily activities

• Maintained daily communication with all clients

• Partake in special center celebrations

• Administered psycho-social portion of multi-functional assessments

Patient Financial Services – Collector, 2002 – 2006

Baptist Hospital, Miami, FL

• Reviewed new claims and assured they have been received & submitted to the correct provider

• Determined if claim has been paid per contracted rate

• Adjusted claims according to the allowable per provider’s agreement

• Reviewed denials and submitted appeals

• Maintained collection reports up-to-date

• Continuous awareness of all health plan contracts including Medicare and Medicaid

• Maintain a professional and positive manner with all insurance personnel and members at all times

Utilization Management Coordinator, 1998 – 2002

Mercy Health/ NHP, Miami, FL

• Responsible for initial first level review of all medical service requests

• Reviewed cases for medical appropriateness, medical necessity and level of care in accordance with utilization review and medical management guidelines, standards and criteria.

• Managed data entry of authorizations and clinical information into the medical management information system

• Maintain utilization management functions in compliance to contracted health plans and agency standards

• Participated in the quality management functions by reviewing and monitoring for designated indicators

• Reviewed medically necessary cases and submitted to the medical director for final determination

• Maintained a positive relationship with referring providers and specialists at all times

Case Management Specialist, 1997- 1998

Neighborhood Health Partnership, Miami, FL

• Responsibilities included; Review established cases, authorize new home health services using Medicare, Medicaid and Commercial guidelines; Notify managers when cases appeared to require full support

• Obtained all medical information for cases presented for special authorizations and forwarded to medical director for review

• Reviewed request for ancillary services to include; Physical, Occupational and Speech therapy as well as Durable Medical equipments, Orthotics and Prosthetics assuring they meet medical management guidelines

• Tracked and monitored all commercial and Medicaid obstetric cases for compliance with prenatal program

• Developed and maintained a positive relationship with members and providers

Education

Master of Science in Psychology, Mental Health – 2007- Present

Carlos Albizu University, Miami, FL

Bachelors of Science in Psychology - 2007

Carlos Albizu University, Miami, FL

Associate of Science in Business Health Management - 2004

City College, Miami, FL

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