José Zayas Montañez
Bayamón
Summary
Bilingual experienced nursing professional bringing demonstrated clinical expertise, leadership skills and technical knowledge. Proficient in updating charts, monitoring medications and working with multidisciplinary teams to optimize patient care. Quality-driven and efficient with strong interpersonal abilities.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Operating Room Nurse (Inpatient/Outpatient)
Bayamón Medical Center
Bayamón
11.2023 - Current
- Provide patients with perioperative care in pre-procedure, operating, and recovery rooms
- Ensure that the operating room runs smoothly and is stocked with all necessary surgical supplies and equipment
- Develop and implement care plans that ensure patients’ security
- Assist in the maintenance and storage of surgical equipment
- Evaluate patients prior to surgery and in postoperative phases
- Monitors patients’ physical and emotional well-being throughout the care continuum
- Communicate with patients and other healthcare professionals to ensure continuity of postoperative care
- Update patient files and medical records
- Adhere to all relevant health and safety standards.
Educator regarding the HIPAA & OSHA laws in a laboratory setting
Dr. Noy Pathology Laboratory
San Juan
07.2013 - Current
- Co-author, revisor, editor & creator of scientific papers & posters; oral presentations; and a consultant for coding & billing Guidelines for Medicare & other entities
- Administrator to one of their Physician’s Practice: Ensure all documentation & credentials stays up to date and are properly submitted to the PR Medical Licensing & Discipline Board
- Provide assistance in the creation of regulatory practice documents for new services that will involve direct patient management
- Serve as a resource to comply with all Federal & State Regulations, as well as Safety in patient management
- Elaborate tools to publish new Ophthalmic Pathology Services around the medical community.
Occupational Health Nurse
Johns Hopkins Hospital (JHH)
Baltimore
03.2022 - 07.2023
- Coordinate the care and safety of employees
- Provide direct employee care based on occupational health principles
- Heighten the achievement of clinical, financial and organizational outcomes
- Facilitate direction to other team members to collaborate and perform occupational health services functions; assist with maintaining these programs when needed by participating in necessary training to promote quality and excellence of care
- Apply case management principles to manage employee referrals to internal and external providers/services
- Promote improvement in Occupational Health Services and organizational systems to optimize employee care
- Utilize employment laws governing regulatory and occupational health such as ADA, FML, Joint Commission; as well as laws governing Alcohol and Drug Testing
- Administer vaccines to both new and current employees following CDC guidelines on a daily basis
- Provide support on a recurrent basis to CMAs in Phlebotomy duties: collection of blood and urine samples; but also perform those functions whenever was on the 24 hour-on-call-shift periods to assess employees that were suspected to be under the influence of illegal substances
- Serve as Qualified Interpreter/Translator for the Spanish language for employees, patients and providers.
Educator, Author, Co-author & Editor of educational modules for Primary Care Physicians (PCPs)
Medical Card System, Inc. (MCS)
San Juan
01.2015 - 07.2022
- Resource & Lead for Projects on a needed basis (e.g., Coding, Clinical Practice Guidelines, HEDIS Measures, etc.)
PREP-PACU-OR-PR REGISTERED NURSE (RN)
Johns Hopkins Health System (JHHS) – Green Spring Station
Lutherville
07.2021 - 02.2022
- Execute the nursing process and participate as an integral part of the interdisciplinary health care team in providing the highest quality of care to the patient: Ophthalmological Surgeries and In-Vitro-Fertilization (IVF; including removal and insertion of eggs)
- Efficient patient monitoring as required per each phase of care
- Safe management of sharps, specimens, and other equipment/supplies
- Knowledge of required patient clearances for surgery per Anesthesia Guidelines
- Cognizant of post-anesthesia discharge requirements, preparations for discharge and discharge education to patients or family members / significant other(s)
- Monitor the actions surrounding the sterile field to guarantee the maintenance of its integrity
- Validate that all supplies and equipment are available and functional
- Actively listen to the patient, surgeon, anesthesiologist, and other collaborators of the surgical team to secure a patient-centered care
- Clear and concise documentation in patient’s medical record (EPIC).
ORCHARD HILL REHAB. & HEALTHCARE CENTER RN
Marquis Health Consulting Services
Towson
05.2021 - 07.2021
- Impart direct nursing care to the residents
- Admit, transfer and discharge patients, as required
- Chart nurses’ notes in a descriptive manner that reflects the care provided to the resident, as well as the resident’s response; and perform other routine charting duties as required by the facility’s policies
- Prepare and administer medications as ordered by the physician
- Ensure that narcotics counts are accurate, before and after every shift
- Alert the on-call- physician for any pertinent changes in the state of health of the resident
- Administer professional services such as: tube feedings, suctions, wound care, colostomy care, and coordinate diagnostic services as ordered by physician
- Review the daily care plans to ensure appropriate care is being rendered
- Supervise the day-to-day care activities performed by CNAs/GNAs, provide education, counseling and perform disciplinary action as necessary.
CAROL BALL MEDICINE UNIT REGISTERED NURSE II
Johns Hopkins Bayview Medical Center
Baltimore
02.2021 - 04.2021
- Bestow professional nursing care according to physician orders and established nursing techniques, procedures, standards and Medical Center administrative policies
- Interview & observe patients in order to assess needs
- Administer medications & monitor intravenous therapeutic treatments
- Assist physicians in administering diagnostic tests & treatments
- Make periodic patient rounds, take vital signs and evaluate patient care provided by LPN’s, technicians, nursing assistants, etc
- Report significant changes in patients’ condition to appropriate nursing or physician professional
- Assist with or implement corrective measures as directed during adverse patient developments
- Maintain current, accurate and complete records of nursing observation and care
- Respond to patient inquiries, complaints and routine service requests
- Explain and record discharge instructions to patients or their families.
FACILITIES CLINICAL VALIDATIONS AUDIT CASE REVIEWER
UnitedHealth Group / Optum Puerto Rico Operations (OPRO)
San Juan
02.2020 - 05.2020
- Investigation, review, and provision of clinical or coding expertise in the application of medical and reimbursement policies within the facilities’ claim adjudication process through file review for the Post-pay phase of the Medicare & Retirement (M&R) and Employer & Individual (E&I) Appeals Lines of Business (LOB).
ADVANCED CLINICAL CASE REVIEWER (C&S / M&R)
UnitedHealth Group / OPRO
San Juan
07.2019 - 01.2020
- Determine accuracy of submitted bill to United Healthcare, via comparison to the medical records, for the Community & State (C&S) and Medicare & Retirement (M&R) LOBs’ Appeals (professional-medical & ancillary services); against coding mastery in review of pre-payment claims: interpretation of state & federal mandates, billing practices, relevant benefit language, reimbursement policies, and consideration of pertinent clinical information on claims with overt billing patterns and make payment or denial recommendation decisions based on findings
- Provide written or verbal communication to senior leadership on root cause identification on key cases.
ADMINISTRATIVE DETERMINATIONS SPECIALIST
Medical Card System, Inc. (MCS)
San Juan
09.2015 - 10.2018
- Design, implement & execute management of Administrative Organization Determinations (ODs) & Appeals in compliance with Medicare, Medicaid, State and Federal regulations
- Oversee management of Clinical Appeals: accurate revision & analysis of received clinical documentation; perform necessary efforts with providers/members to obtain missing information; discuss case with MCS’s Medical Advisor for case’s determination; emit final written & verbal determination to involved legal parties
- Train & supervise new nursing personnel during training period: Translate concepts into practice; Provide explanations & information to others on difficult issues; Coach, provide feedback, and guide others; and Act as a resource for others with less experience
- Prepare full written report with all relevant files, for Appeals that are referred to an Independent Revision Entity (Maximus Federal Services), obliged to all its instructions
- Generate weekly reports of all completed cases, utilizing Medicare’s reporting requirements, and daily reconciliation of all referred cases
- Provide support in revision & completion of relevant operational policies & procedures, as well as written notifications templates to enrollees & providers, associated with the OD & Appeals processes.
Office RN
Doctors on Call
05.2018 - 07.2018
- Perform Initial clinical assessment: physical examination, vital signs, drug reconciliation, patient history and handling of medical records; for both the office & home care settings
- Aid for administrative services concerning health insurances, particularly, billing and payment.
CLINICAL MEDICAL POLICY SPECIALIST & TECHNICIAN
Medical Card System, Inc. (MCS)
San Juan
05.2011 - 09.2015
- Research, analysis & synthesis of scientific literature relevant to medical procedures, Durable Medical Equipment (DME), Pharmaceutical Drugs & Emerging Technologies, Experimental Services, & Clinical Practice Guidelines
- Strong technical writing skills with experience creating clinical & professional documentation
- Research source information from CMS and state Medicaid sources
- Medical Policies, and their corresponding presentations to the MCS Medical Advisory Committee: experience presenting to senior level management
- Yearly revision of existing medical policies & adopted Clinical Practice Guidelines on a monthly basis
- Propose & assign relevant coding information to MCS’s active medical policies & verifying their validity, according to the American Medical Association’s Coding Manuals (i.e., CPT, HCPCS, ICD-9, ICD-10)
- Worked with application development to ensure proper claims processing
- Management & resolution of consultations, mainly for Clinical Organization Determinations (ODs) for both the Commercial & Advantage LOBs, as support to medical consultants, Directors and nurses
- In other words: Reviewing, researching and responding to client issues, while anticipating customer needs and proactively develop solutions to meet them
- Accurately interpret national reimbursement policies & coding guidelines for utilization.
Customer Service Representative (Call Center)
Medical Card System, Inc. (MCS)
San Juan
08.2009 - 05.2011
- Receive & handle the following LOBs: Providers, Commercial (Employer& Individual), Advantage & Medicaid
- Responsible for orienting doctors, hospitals, medical facilities & MCS policyholders regarding health benefits, insurance information, bills/claims/reimbursements, paychecks, pre-authorizations, taking account payments, creating coverage certifications, amongst others
- Assess and interpret customer needs and requirements.
Customer Service Representative
Caribbean Temporary Services (CTS)
San Juan
10.2008 - 07.2009
- Face to face and telephonic promoting, selling & renewing the health plan contract for government agencies, and full orientation concerning health insurance’s benefits/coverage (e.g., First Medical Health Plan).
Education
Bachelor of Science in Nursing (BSN) -
NUC UNIVERSITY
01.2013
Associate’s Degree in Nursing (ADN – Cum Laude) -
NUC UNIVERSITY
01.2011
Bachelor of Science; Major in Biology with Human Approach with a Minor in Science High School Education -
University of puerto rico
01.2008
Skills
- Inquisitive & Analytical
- Self-starter
- Team oriented
- Continual improvement
- Innovative
- Communicative
- Assertive in conflict management
- Hard worker
- Research & Publications
- Proactive resolution skills
- Organized & flexible
- Proficient in English & Spanish
- Microsoft Office (10 years of experience): Outlook, Word, Excel, Publisher, PowerPoint
- Cority, Orchid, VMS, Epic, Pyxis, Nova Strip Glucose Meter, Alaris IV System, JHMI My Learning
- Facets, Cosmos, PICTS, ODAR, Knowledge Now, DocDNA, Doc360, WebStrat, EncoderPro (Optum 360), ECAA, CTS, Content Manager, IDRS, SAS, PEGA-CR, PEGA- CM, Stars, I-CUE, Tips Historical
- Beacon platform; CCM; Envolve/Opticare; Dental Netclaimz; PCH; Power MHS; Sibel/Cognos; CCMS Care Manager; InterQual; Fastrieve; I-Health; Provinet
Fax
+1 787-906-0314
References
Please refer to provided attachment.
Certification
- Puerto Rico (PR) RN License 70438 and Registration 169938.
- PR College of Nursing Active Membership: 46515.
- Maryland RN License R245437.
- BLS Certification: 235414006602.
- ACLS Certification: 245624154193.
- PALS Certification: 225421847297.
- NRP Certification: 1ib3qniy2hik3pmfkxhspqoc 8JZ-0395.
- Heartsaver First Aid Certification: 236034006983.
Languages
Spanish
First Language
English
Proficient (C2)
C2
References
References available upon request.
Timeline
Operating Room Nurse (Inpatient/Outpatient)
Bayamón Medical Center
11.2023 - Current
Occupational Health Nurse
Johns Hopkins Hospital (JHH)
03.2022 - 07.2023
PREP-PACU-OR-PR REGISTERED NURSE (RN)
Johns Hopkins Health System (JHHS) – Green Spring Station
07.2021 - 02.2022
ORCHARD HILL REHAB. & HEALTHCARE CENTER RN
Marquis Health Consulting Services
05.2021 - 07.2021
CAROL BALL MEDICINE UNIT REGISTERED NURSE II
Johns Hopkins Bayview Medical Center
02.2021 - 04.2021
FACILITIES CLINICAL VALIDATIONS AUDIT CASE REVIEWER
UnitedHealth Group / Optum Puerto Rico Operations (OPRO)
02.2020 - 05.2020
ADVANCED CLINICAL CASE REVIEWER (C&S / M&R)
UnitedHealth Group / OPRO
07.2019 - 01.2020
Office RN
Doctors on Call
05.2018 - 07.2018
ADMINISTRATIVE DETERMINATIONS SPECIALIST
Medical Card System, Inc. (MCS)
09.2015 - 10.2018
Educator, Author, Co-author & Editor of educational modules for Primary Care Physicians (PCPs)
Medical Card System, Inc. (MCS)
01.2015 - 07.2022
Educator regarding the HIPAA & OSHA laws in a laboratory setting
Dr. Noy Pathology Laboratory
07.2013 - Current
CLINICAL MEDICAL POLICY SPECIALIST & TECHNICIAN
Medical Card System, Inc. (MCS)
05.2011 - 09.2015
Customer Service Representative (Call Center)
Medical Card System, Inc. (MCS)
08.2009 - 05.2011
Customer Service Representative
Caribbean Temporary Services (CTS)
10.2008 - 07.2009
Bachelor of Science in Nursing (BSN) -
NUC UNIVERSITY
Associate’s Degree in Nursing (ADN – Cum Laude) -
NUC UNIVERSITY
Bachelor of Science; Major in Biology with Human Approach with a Minor in Science High School Education -
University of puerto rico
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