Nestor E. Nazario Rosado
Melbourne
Summary
Results-driven health insurance professional with over six years of experience in clinical, quality, and managed care. Proven ability to analyze complex clinical documentation, resolve appeals, and collaborate effectively with clinical and leadership teams. Adept at optimizing workflows, training team members, and enhancing operational efficiency to deliver exceptional outcomes.
Overview
7
7
years of professional experience
Work History
Clinical Quality Interventions/QI Compliance
Molina Healthcare
Remote
03.2025 - Current
- Implement key quality improvement strategies, including provider, member, and community-based interventions to reduce barriers to care and improve health outcomes.
- Support preparation and execution of Quality Improvement Compliance surveys, including NCQA accreditation and federal/state regulatory reviews.
- Monitor, track, and ensure timely and accurate completion of quality activities and deliverables for reporting to departmental leadership and cross-functional teams.
- Conduct data collection, reporting, and performance monitoring for key quality and regulatory measurement activities.
- Prepare detailed narrative reports interpreting regulatory and accreditation requirements, explaining quality programs, outcomes, limitations, and findings.
- Create, manage, and compile required documentation to support ongoing quality improvement functions and compliance readiness.
- Lead and participate in quality improvement meetings, initiatives, and cross-departmental discussions to drive alignment and results.
- Evaluate quality projects and program outcomes to identify trends, gaps, and opportunities for process improvement.
- Identify and escalate process gaps or compliance risks to management, recommending remediation strategies as needed.
- Collaborate with internal departments to ensure adherence to prescribed quality standards and continuous improvement initiatives.
- Perform additional quality improvement tasks, projects, and duties as assigned to support organizational goals.
Senior Risk Management Professional
Humana
01.2023 - 02.2025
- Identified and analyzed potential sources of loss to minimize organizational risk through in-depth evaluations of complex issues.
- Estimated financial impacts of losses and developed cost-effective risk controls.
- Collaborated across functions to assess and communicate business risks, influencing departmental strategy.
- Made independent decisions on technical approaches and project components, with considerable autonomy in determining objectives and solutions.
Risk Management Professional
Humana
01.2022 - 01.2023
- Assisted with minimizing risk exposure by reviewing claim validity and viability against coverage standards.
- Developed short-term goals and long-term strategic plans to improve risk control and mitigation.
- Trained staff in risk management policies and monitored compliance to control company liability.
- Promoted enterprise-level risk management practices and helped instill strong culture focused on protective policies and procedures.
Grievance Appeals Specialist
Humana
01.2021 - 01.2022
- Managed client denials by analyzing clinical documentation, determining appeal eligibility, and delivering final decisions in collaboration with clinical teams.
- Investigated and resolved member/provider appeals, preparing case files for Grievance & Appeals workgroup presentation to medical directors and leadership.
- Led provider outreach to gather necessary documentation and assisted in training team members on workflows and policies.
- Drafted adverse determination and approval letters for Utilization Management decisions.
- Evaluated internal policies to enhance operational efficiency, submitting cases for auditing to propose solutions for complex issues.
Call Center Representative
UnitedHealthcare
03.2019 - 12.2020
- Managed high call volumes while providing exceptional customer support and maintaining professional composure.
- Developed rapport with customers through empathetic listening skills, creating positive experiences even during difficult conversations.
- Handled escalated calls professionally, effectively resolving complex issues and ensuring client satisfaction at all times.
- Mastered multiple software systems for seamless navigation during calls, improving efficiency and reducing hold times for customers.
- Enhanced customer satisfaction by efficiently addressing and resolving inquiries in a timely manner.
Education
Bachelor of Science - Nursing
Universidad Interamericana De Puerto Rico
Rio Piedras, PR06.2020
High School Diploma -
Antilles High School
Fort Buchanan, Puerto Rico06.2012
Skills
- Time Management
- Regulatory interpretation
- Medical Terminology
- Excellent Communication
- Quality improvement
- Team Collaboration
- Leadership skills
- Quality Assurance
- Critical Thinking
- Investigational product management
- Data Analysis
- Workflow Management
- Policy Knowledg
- Case analysise
- Risk assessment
- Data analysis
- Process improvement
- Project management
- Team leadership
Languages
- English
- Spanish
References
References available upon request.
Timeline
Clinical Quality Interventions/QI Compliance
Molina Healthcare
03.2025 - Current
Senior Risk Management Professional
Humana
01.2023 - 02.2025
Risk Management Professional
Humana
01.2022 - 01.2023
Grievance Appeals Specialist
Humana
01.2021 - 01.2022
Call Center Representative
UnitedHealthcare
03.2019 - 12.2020
Bachelor of Science - Nursing
Universidad Interamericana De Puerto Rico
High School Diploma -
Antilles High School