JEAMIE LEE RIVERA COTTO
Bayamon
Summary
Registered Nurse with over 17 years of clinical and managed care experience specializing in Transition of Care, Care Coordination, Case Management, Utilization Management, discharge planning, medication reconciliation, chronic disease management, and reducing hospital readmissions. Extensive experience serving Medicare Advantage members while collaborating with interdisciplinary teams.
Overview
1
1
Certification
7
7
years of post-secondary education
16
16
years of professional experience
Work History
Discharge Planner / Care Coordinator
MMM
05.2026 - Current
- Coordinated safe transitions from hospital to home, ensuring continuity of care.
- Assessed discharge needs and identified barriers to care, fostering smoother patient transitions.
- Coordinated DME, home health services, and follow-up appointments to support patient recovery.
- Collaborate with multidisciplinary teams to improve continuity of care.
Clinical Management Nurse - Transition of Care
Best Health Group / Triple-S Advantage
02.2026 - 05.2026
- Performed post-discharge outreach.
- Completed medication reconciliation.
- Educated patients and caregivers.
- Helped reduce avoidable readmissions through coordinated care.
Pre-Authorization / Utilization Management Nurse
Humana Puerto Rico
01.2017 - 12.2025
- Reviewed medical necessity using InterQual and CMS guidelines.
- Supported discharge planning and care coordination.
- Collaborated with physicians and providers.
- Reviewed medical necessity for inpatient and outpatient services using InterQual and MCG clinical criteria.
- Processed pre-authorizations for surgeries, diagnostic imaging, durable medical equipment (DME), medications, and specialty services.
- Collaborated with physicians, specialists, hospitals, and provider offices to obtain and review clinical documentation.
- Provided backup support to the Discharge Planning/Transition of Care team, assisting with safe patient transitions from hospital to home.
- Coordinated care with interdisciplinary teams to promote continuity of care and reduce readmissions.
- Performed internal clinical audits to ensure documentation accuracy, regulatory compliance, and quality standards.
- Maintained productivity and quality metrics while managing a high-volume caseload.
- Communicated authorization determinations and clinical recommendations to providers and members.
RN Case Manager
Triple-S
01.2011 - 12.2017
- Managed chronic disease populations.
- Developed individualized care plans.
- Connected members with community resources.
- Conducted comprehensive in-home patient assessments to evaluate clinical status, functional abilities, medication adherence, and social determinants of health.
- Visited physician offices to collect, review, and validate clinical documentation supporting members' care management needs.
- Collaborated with Primary Care Providers, specialists, caregivers, and interdisciplinary teams to coordinate comprehensive patient care.
- Developed individualized care plans for members with chronic and complex medical conditions.
- Identified high-risk members requiring intensive case management and ongoing clinical follow-up.
- Educated patients and caregivers on disease management, medication adherence, preventive care, and available community resources.
- Coordinated referrals to specialists, home health agencies, durable medical equipment (DME), and community support services.
Education
Master of Science - Nursing
Universidad Ana G Mendez
Puerto Rico 08.2017 - 06.2020
Bachelor of Science - Nursing
Universidad Interamericana
Bayamón, Puerto Rico 08.2004 - 06.2008
Registered Nurse -
Puerto RicoSkills
- Transition of Care (TOC)
- Care Coordination
- Discharge Planning
- Case Management
- Medication Reconciliation
- Readmission Prevention
- Medicare Advantage
- InterQual & MCG
- CMS & NCQA Guidelines
- Patient Education
- Chronic Disease Management
- Bilingual (English/Spanish)
Certification
Registered Nurse, Puerto Rico
Timeline
Discharge Planner / Care Coordinator
MMM
05.2026 - Current
Clinical Management Nurse - Transition of Care
Best Health Group / Triple-S Advantage
02.2026 - 05.2026
Master of Science - Nursing
Universidad Ana G Mendez
08.2017 - 06.2020
Pre-Authorization / Utilization Management Nurse
Humana Puerto Rico
01.2017 - 12.2025
RN Case Manager
Triple-S
01.2011 - 12.2017
Bachelor of Science - Nursing
Universidad Interamericana
08.2004 - 06.2008