Yadiris A. Santaella Rivera
San Juan
Summary
Dedicated Registered Nurse with over a decade of experience in clinical assessment, critical thinking, and coordination of patient-centered healthcare services. Proficient in evaluating patient needs while ensuring compliance with HIPAA and Medicare regulations and implementing evidence-based interventions. Expertise in case management, care coordination, and advocacy for vulnerable populations, with a strong commitment to enhancing patient outcomes through solution-focused strategies and interdisciplinary collaboration. Eager to leverage clinical expertise and coordination skills in a role that promotes individual and community well-being.
Overview
13
13
years of professional experience
Work History
Preauthorization Nurse (Utilization Management)
Humana, Inc.
02.2017 - Current
- Performed comprehensive medical necessity and level-of-care reviews for Part-B medications, oncology treatments, discharges, DME, OPS, auto-approvals, and LTC transitions, applying advanced utilization management and case management principles.
- Applied clinical judgment using Medicare guidelines, MCG, and InterQual criteria to evaluate authorization requests, document determinations, and escalate complex cases to medical directors when appropriate.
- Consistently maintained above-average productivity while ensuring precise documentation and strict compliance with federal, regulatory, and organizational standards.
- Provided clear guidance to providers, coordinated efficiently with external vendors, and supported cross-functional workflows to enhance continuity of care.
- Demonstrated reliability and leadership by contributing to departmental goals and participating in special projects that improved operational efficiency and service quality.
Clinical Case Manager (CarePlus)
Humana, Inc.
02.2017 - 02.2019
- Conducted comprehensive beneficiary admissions by reviewing records, completing intake interviews, and delivering program orientations.
- Applied advanced case management skills to assess eligibility for therapeutic, medical, psychosocial, and psychiatric services, and to develop individualized, goal-driven treatment plans.
- Coordinated multidisciplinary resources, facilitated access to services, and ensured continuity of care through ongoing monitoring, attendance verification, outcome evaluation, crisis intervention, and proactive advocacy.
- Maintained meticulous, compliant documentation and delivered structured progress updates during interdisciplinary team meetings to support integrated care planning, remove barriers, and optimize beneficiary outcomes.
Clinical Coordinator & Community Health Educator
Centers for Disease Control Foundation (CDC)
11.2016 - 02.2017
- Implemented the Z-CAN program across Puerto Rico to prevent Zika-related birth complications through community outreach and contraceptive access.
- Delivered educational workshops, coordinated timely referrals with healthcare providers, and managed inventory to ensure equitable distribution of contraceptives.
- Supported public health initiatives, raising awareness, and enhancing program impact in underserved communities.
Clinical Research Nurse Coordinator
University of Puerto Rico, Medical Sciences Campus PRCTRC
07.2012 - 11.2016
- Conducted literature reviews and assisted in developing study protocols, research instruments, and interview guides.
- Utilized nursing clinical skills, including blood sample collection, IV infusion, and assisting physicians with procedures, while obtaining informed consent and collecting clinical and survey data with strict adherence to confidentiality and research ethics.
- Performed participant interviews, documented study progress, and ensured compliance with research guidelines.
- Supervised research teams, managed laboratory inventory, audited patient records for accuracy, and supported faculty by preparing datasets and summarizing findings for reports, manuscripts, and presentations.
Education
Medical Billing Certification -
Asociación de Facturadores Médicos de Puerto Rico
Bayamón, P.R.03.2019
Bachelor of Science - Nursing
University of Puerto Rico, Medical Sciences Campus
San Juan, P.R.06.2012
Master of Science - Healthcare Management
Ana G. Menedez University
Orlando, Fl06-2027
Skills
- Compliance record review
- Community outreach
- Clinical proficiency in blood collection and IV infusion
- Research protocol development
- Case management expertise
- Crisis intervention expertise
- Utilization review expertise
- Medical coding professional
- Effective communication and leadership
- Proficient in MS Office Suite and Zoom
- Bilingual communication proficiency
Timeline
Preauthorization Nurse (Utilization Management)
Humana, Inc.
02.2017 - Current
Clinical Case Manager (CarePlus)
Humana, Inc.
02.2017 - 02.2019
Clinical Coordinator & Community Health Educator
Centers for Disease Control Foundation (CDC)
11.2016 - 02.2017
Clinical Research Nurse Coordinator
University of Puerto Rico, Medical Sciences Campus PRCTRC
07.2012 - 11.2016
Bachelor of Science - Nursing
University of Puerto Rico, Medical Sciences Campus
Medical Billing Certification -
Asociación de Facturadores Médicos de Puerto Rico
Master of Science - Healthcare Management
Ana G. Menedez University
Community Service & Volunteer Work
- Humana – Community Volunteer
Contributed 16 hours annually to community service initiatives, including beach clean-ups and support for local animal shelters, reflecting commitment to corporate social responsibility and community engagement. - San Juan Veteran Affairs Medical Center, San Juan, P.R. – Volunteer
Assisted patients with activities of daily living (ADLs) and supported post-operative care in the surgical ward for six consecutive months, enhancing patient comfort and recovery while gaining hands-on clinical experience. - Iglesia Bautista Luz del Mundo, Trujillo Alto, P.R. – Teacher/Volunteer
Served as a biblical school teacher during summer camps for three consecutive years, providing educational support and mentorship to children in the community.