Angelica Rodriguez Lopez
Quebradillas,Puerto Rico
Summary
Dedicated Registered Nurse and Clinical/DRG Validation Analyst with over 8 years of experience in hospital departments and health insurance claims. Expert in medical necessity determination, documentation review, and conducting detailed audits for Medicare and retired inpatient clinical documentation. Proven leader in Itemized Bill Review (IBR), offering training and support to teams, and driving improvements in clinical processes. Eager to leverage expertise in a challenging nurse and auditor role to contribute to healthcare excellence.
Overview
7
7
years of professional experience
1
1
Certification
Work History
IBR Clinical/DRG and Clinical Validation Analyst
OPTUM-United health Group
08.2022 - Current
- As a Clinical Subject Matter Expert (SME) for Itemized Bill Review (IBR) of both inpatient and outpatient claims, I lead the IBR review process, providing support to my team and offering training to new hires. I guide them throughout the entire processes and conduct internal quality audits within my team, and assist other teams as needed. In addition, I lead support meetings to discuss workflow processes, analyze production performance, and identify areas for improvement and emerging trends to minimize errors.
- In my role as a Clinical Validation Analyst, I audit inpatient medical records, performing both clinical and DRG (Diagnosis-Related Group) validation reviews to ensure the accuracy of documentation. These reviews focus on post-pay Medicare and retired inpatient claims to verify that reimbursements made to facilities are accurate, based on the diagnosis billed, the patient’s discharge disposition, and the supporting medical documentation. All findings are documented in detailed rational letters and communicated to facilities, including unsupported codes, discharge disposition changes, and DRG modifications.
- I manage daily production claims, prioritizing tasks while maintaining a strong focus on quality. I collaborate closely with team members to meet project goals and deadlines, ensuring successful outcomes.
Process specialist RN
Infosys-Horizon Blue Cross Blue Shield of New Jersey
02.2021 - 07.2022
- Responsible for processing health claims submitted by providers, using medical policies, patient benefits, authorizations, referrals, documented clinical data, and billing codes to determine if the procedures performed meet established standards and are medically necessary for approval. In cases where the procedure is not deemed necessary, my responsibilities include preparing comprehensive cases for physician review and documenting the physician’s final determination.
- I efficiently managed time to ensure timely completion of tasks, consistently meeting production goals and maintaining the required quality standards.
Graduate Nurse, MSN, RN
Mayaguez Medical Center Hospital
08.2017 - 12.2020
- Department of Surgery
Responsible for the care of patients undergoing all types of surgery and amputations. Administer medications and provide treatment to patients with general medical conditions, including heart, respiratory, and intestinal diseases, among others. - Pre-Admission Department
Pre-admit patients scheduled for outpatient surgeries and hospitalizations. Responsibilities include sample collection, EKG, medical record preparation including anesthesia required documentation, and referrals to specialists in internal medicine, pulmonology, cardiology, pediatrics, and more. - Blood Bank
Conduct patient interviews, monitor vital signs, collect blood from voluntary donors, and perform therapeutic phlebotomies for patients with hematological conditions. Organize and manage blood donation events in the northwest region. - Maternal and Child Department
Monitor vital signs, maintain documentation, administer medications, assist in the recovery of patients after cesarean sections, and provide blood transfusions as required.
Education
MASTER DEGREE -
UNIVERSIDAD INTERAMERICANA DE ARECIBO
01.2018
BACHELOR DEGREE -
NATIONAL UNIVERSITY
01.2009
Skills
- Bilingual (English/Spanish)
- Computer skills and management of programs/applications
- Responsible
- Organized
- Punctual
- Process Validation
- Documentation Review
- Ability to learn quickly
Certification
Active Nurse License
- Permanent Registered Nurse (Master’s Degree) License
- Permanent Registered Nurse (Bachelor’s Degree) License
- Registered Nurse License with US Florida Endorsement
Certifications
- Basic life support (BLS)
- Neonatal resuscitation program (NRP)
References
Available on request
Timeline
IBR Clinical/DRG and Clinical Validation Analyst
OPTUM-United health Group
08.2022 - Current
Process specialist RN
Infosys-Horizon Blue Cross Blue Shield of New Jersey
02.2021 - 07.2022
Graduate Nurse, MSN, RN
Mayaguez Medical Center Hospital
08.2017 - 12.2020
MASTER DEGREE -
UNIVERSIDAD INTERAMERICANA DE ARECIBO
BACHELOR DEGREE -
NATIONAL UNIVERSITY