Summary
Overview
Work History
Education
Skills
Credentials
Timeline
Generic

Alberto Muñoz

Bayamon

Summary

With a solid experience as a Registered Nurse, boasting over a decade of hands-on clinical experience, and further enriched by two years as a Certified Professional Coder, I bring to the table not only my expertise but also my leadership skills honed over two years supervising multiple lines of business and processes. I am actively seeking a new role where I can apply my comprehensive knowledge of medical and software tools within a progressive practice. My strong communication abilities, leadership acumen, organizational prowess, and time management skills are all geared towards one goal: to continually learn, adapt, and excel in the fast-paced healthcare environment.

Overview

13
13
years of professional experience

Work History

Clinical Care Manager

Healthmap Solutions
01.2024 - Current
  • The Clinical Care Manager is responsible for fostering long-term relationships with physicians, physician office staff, and HealthMap members participating in the Kidney Management Program
  • Liaison and Relationship Building: Act as a bridge between Healthmap, provider practices, and Healthmap members
  • Cultivate new provider and partner relationships to enhance engagement for both providers and members
  • Manage an assigned caseload effectively
  • Health Outcomes Improvement: Analyze provider-specific data to identify opportunities for enhancing health outcomes among Healthmap Solutions members
  • Implement best practices, process improvements, and Kidney Health Management interventions
  • Address areas of low provider performance using HEDIS/STAR measures
  • Provider Education: Educate provider offices on topics related to Chronic Kidney Disease, End Stage Renal Disease, and Renal Replacement Therapies
  • Collaborate with physicians and their staff to identify members who would benefit from Care Navigation support
  • Member Advocacy: Empower Healthmap members by educating them about kidney health and related co-morbid conditions
  • Serve as a liaison between members, their support networks, treating physicians, and ancillary providers
  • Assist members in achieving individualized health goals
  • Metrics and Compliance: Be accountable for individual and departmental metrics and key performance indicators
  • Ensure timely and accurate delivery of reports to internal and external stakeholders
  • Maintain thorough documentation of provider meetings and member interactions, adhering to National Committee for Quality Assurance (NCQA) standards
  • Evaluation of departmental and medical office performance metrics, identification of HEDIS opportunities, creation of pivot tables and visual charts to enhance data visualization and presentation for medical offices, managers, and organizational leaders, as well as data analysis
  • Policy Adherence: Uphold Healthmap policies and procedures, ensuring compliance with HIPAA privacy laws and other regulations
  • Additional Responsibilities: Perform any other related duties as assigned

Clinical Investigations Auditor

Optum, part of UnitedHealth Group, Inc.
05.2023 - 12.2023
  • Company Overview: Continually fostering a secure and innovative environment that underscores employee satisfaction and cultural development
  • Conducted in-depth investigations and reviews, leveraging clinical and coding expertise to ensure adherence to medical and reimbursement policies within the claim adjudication process
  • Conducted audits on Fraud, Waste, and Abuse from the initial review stage, serving as a secondary reviewer to ensure the quality of the final output
  • Provided educational guidance to peers on coding best practices, process optimization, and the implementation of guidelines and policies
  • Performed meticulous clinical coding reviews to guarantee the accuracy of medical coding and compliance with relevant standards
  • Provided robust clinical support and shared expertise with fellow investigators, fostering a collaborative and knowledge-rich environment
  • Proficient in utilizing platforms such as iDRS, Fastrieve, Filenet, CPW, NICE, and Detects to enhance investigative processes
  • Applied Certified Professional Coder certification to enhance understanding and analysis of cases, contributing to the improvement of the healthcare system
  • Continually fostering a secure and innovative environment that underscores employee satisfaction and cultural development

Supervisor for Expedited Medicare Appeals and Grievances Process (DSNP)

Optum, part of UnitedHealth Group, Inc.
01.2023 - 05.2023
  • Collaborated with business partners in Ireland, the USA, and India to ensure seamless communication and effective project management
  • Coordinated, supervised, and held accountable for the daily activities of business support, technical or production team, or unit
  • Ensured client satisfaction by measuring work quality output and implementing corrective measures as needed
  • Managed inventory and prioritized tasks to ensure timely completion of projects
  • Set priorities for the team to ensure task completion and coordinated work activities with other supervisors
  • Developed plans to meet short/long-term objectives and identified and resolved operational problems using defined processes, expertise, and critical judgment
  • Managed time sheets for the team while ensuring compliance with company policies

Supervisor for Member Appeals and Grievances in C&S (Medicaid)

Optum, part of UnitedHealth Group, Inc.
10.2021 - 01.2023
  • Collaborated with business partners in USA, and India to ensure seamless communication and effective solution driven management
  • Facilitated high-level meetings, such as KMI (Key Management Infrastructure Meetings), to cover manager and peers when they were out of the office, ensuring the continuous movement of the line of business and minimizing the impact on inventory and employee’s performance
  • Managed various lines of business to cover managers and ensure deadlines were met
  • Coordinated, supervised, and held accountable for the daily activities of business support, technical or production team, or unit
  • Ensured client satisfaction by measuring work quality output and implementing corrective measures as needed
  • Managed inventory and prioritized tasks to ensure timely completion of projects
  • Set priorities for the team to ensure task completion and coordinated work activities with other supervisors
  • Developed plans to meet short/long-term objectives and identified and resolved operational problems using defined processes, expertise, and critical judgment
  • Managed time sheets for the team while ensuring compliance with company policies
  • Executed comprehensive analysis to adapt to continuous changes, leading to impactful and positive resolutions
  • This involved direct supervision of staff, managing changes in line of business, and implementing new policies, software, and hardware
  • Served as the primary liaison for employees and business partners to ensure adherence to business compliance

Sr Clinical Investigation Analyst – Recovery Resolutions

Optum, part of UnitedHealth Group, Inc.
04.2019 - 10.2021
  • Conducted in-depth investigations and reviews, leveraging clinical and coding expertise to ensure adherence to medical and reimbursement policies within the claim adjudication process
  • Performed meticulous clinical coding reviews to guarantee the accuracy of medical coding and compliance with relevant standards
  • Provided robust clinical support and shared expertise with fellow investigators, fostering a collaborative and knowledge-rich environment
  • Proficient in utilizing platforms such as iDRS, Fastrieve, Filenet, CPW, NICE, and Detects to enhance investigative processes
  • Applied Certified Professional Coder certification to enhance understanding and analysis of cases, contributing to the improvement of the healthcare system

Registered Nurse, Emergency Department

Ashford Presbyterian Community Hospital – El Presby
10.2018 - 04.2019
  • Experience with Adults, Pediatric and geriatric population
  • Registered Nurse at Emergency Room (Adults, Pediatrics & ICU)
  • Provided immediate and effective medical care to patients in the emergency department, managing conditions such as heart attacks, strokes, and severe injuries
  • Collaborated with a multidisciplinary team of healthcare professionals to develop and implement comprehensive patient care plans
  • Performed triage upon patient arrival to prioritize treatment based on the severity of condition
  • Administered medications, performed procedures, and closely monitored patient vital signs
  • Communicated effectively with patients and their families, providing emotional support and education about treatment plans
  • Documented all patient information accurately and completely in the electronic medical record system
  • Adhered to all hospital policies and procedures, maintaining a safe and clean working environment
  • Acted as a key liaison between various hospital departments, implementing strategies to optimize resource allocation and reduce capacity requirements
  • This involved enhancing inter-departmental communication, coordinating schedules, implementing a hospital-wide patient flow system, cross-training staff, and utilizing data-driven decision making to identify areas for improvement

RN – Blood Components Collector

Banco de Sangre de Servicios Mutuos, Inc.
06.2018 - 10.2018
  • As a Nurse Blood Components Collector, I assess patients, collect blood, separate components, document donations, provide donor care, maintain equipment, and collaborate with the healthcare team

Registered Nurse, Emergency Department

Doctors Center Hospital, Inc.
06.2014 - 05.2018
  • As an Emergency Department Registered Nurse, I provide immediate care to patients in critical condition, perform triage, administer treatments, collaborate with the medical team, and ensure patient comfort and safety

Registered Nurse, Emergency Department

Vega Alta Community Health, Inc.
05.2014 - 06.2014
  • As an Emergency Department Registered Nurse, I provide immediate care to patients in critical condition, perform triage, administer treatments, collaborate with the medical team, and ensure patient comfort and safety

Nursing Professor

Dewey University, Inc.
03.2012 - 11.2012
  • As a Nursing Professor at a college, I design and deliver lectures, supervise clinical practicums, assess student performance, contribute to curriculum development, and engage in academic research and publication

Education

master’s degree - EXECUTIVE NURSING

AGM UNIVERISTY
05.2022

CERTIFIED PROFESSIONAL CODER -

AAPC
12.2020

BACHELLORS DEGREE - NURING

NUC UNIVERISTY
06.2016

Skills

  • Keyboarding Skills
  • Computers (Hardware & Software)
  • High Risk/Alert medications
  • Blood Components Administration
  • Medical terminology
  • Interpersonal relations
  • Office Applications
  • Word
  • Excel
  • Power Point
  • OneNote
  • Outlook
  • Leadership Skills
  • Working under pressure
  • CPR
  • Conscious Sedation
  • Intubation
  • Active CPR code
  • Chronic Disease Management
  • Discharge Planning
  • Individual Therapy
  • Direct Patient Care
  • Quality Improvement

Credentials

  • RN
  • MSN-NA
  • CPC

Timeline

Clinical Care Manager

Healthmap Solutions
01.2024 - Current

Clinical Investigations Auditor

Optum, part of UnitedHealth Group, Inc.
05.2023 - 12.2023

Supervisor for Expedited Medicare Appeals and Grievances Process (DSNP)

Optum, part of UnitedHealth Group, Inc.
01.2023 - 05.2023

Supervisor for Member Appeals and Grievances in C&S (Medicaid)

Optum, part of UnitedHealth Group, Inc.
10.2021 - 01.2023

Sr Clinical Investigation Analyst – Recovery Resolutions

Optum, part of UnitedHealth Group, Inc.
04.2019 - 10.2021

Registered Nurse, Emergency Department

Ashford Presbyterian Community Hospital – El Presby
10.2018 - 04.2019

RN – Blood Components Collector

Banco de Sangre de Servicios Mutuos, Inc.
06.2018 - 10.2018

Registered Nurse, Emergency Department

Doctors Center Hospital, Inc.
06.2014 - 05.2018

Registered Nurse, Emergency Department

Vega Alta Community Health, Inc.
05.2014 - 06.2014

Nursing Professor

Dewey University, Inc.
03.2012 - 11.2012

master’s degree - EXECUTIVE NURSING

AGM UNIVERISTY

CERTIFIED PROFESSIONAL CODER -

AAPC

BACHELLORS DEGREE - NURING

NUC UNIVERISTY

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