Performance Monitor Specialist (Clinical Auditor), RN - Centene Corporation / Superior Health Plan - San Antonio, Texas
(2022-07)
- Review 150+ clinical records monthly while maintaining 98%+ IRR compliance and meeting all productivity targets. Conduct comprehensive clinical audits and documentation reviews to evaluate compliance with organizational, state, CMS, and NCQA performance standards.
- Analyze clinical records, health assessments, interventions, and care management documentation to identify compliance trends and performance improvement opportunities.
- Collaborate with operational leaders and interdisciplinary teams to strengthen quality assurance processes and regulatory adherence.
- Participate in the development, validation, and ongoing refinement of clinical review tools to ensure accurate measurement of performance standards.
- Review policies, procedures, training materials, program descriptions, and contractual requirements to assess alignment with regulatory and organizational expectations.
- Escalate compliance concerns and documentation deficiencies to appropriate stakeholders for corrective action.
- Support preparation and readiness activities for state, CMS, and NCQA audits through targeted record reviews and compliance monitoring.
- Present audit findings and recommendations to leadership and operational teams to drive quality improvement initiatives.
- Consistently meet or exceed established productivity and inter-rater reliability (IRR) standards while maintaining high audit accuracy.
- Utilize strong analytical and clinical judgment skills to evaluate healthcare delivery and documentation practices.
Prior Authorization Nurse, LVN/RN - Centene Corporation / Superior Health Plan - San Antonio, Texas
(2013-04 - 2022-07)
- Performed medical necessity reviews utilizing evidence-based clinical criteria and regulatory guidelines to determine appropriateness of requested healthcare services.
- Evaluated authorization requests across multiple levels of care while ensuring compliance with organizational and regulatory requirements.
- Collaborated with providers, care teams, and medical directors to facilitate timely authorization decisions and continuity of care.
- Coordinated discharge planning and transitions of care to promote appropriate utilization of healthcare resources.
- Maintained accurate clinical documentation within health management systems while ensuring compliance with regulatory standards.
- Educated providers and internal stakeholders regarding utilization management processes and authorization requirements.
- Identified opportunities to streamline workflows and improve authorization review processes.
- Served in a Team Lead capacity by assigning work, mentoring staff, and supporting departmental operations. Trained and onboarded 15+ new staff members contributing to improved departmental productivity and quality outcomes.
- Recognized for leadership, clinical expertise, and ability to support operational efficiency in a high-volume environment.
Clinical Nurse Specialist, LVN - Kinetic Concepts, Inc. - San Antonio, Texas
(2009-07 - 2013-04)
- Conducted telephonic clinical assessments to monitor wound progression and treatment effectiveness for patients receiving Negative Pressure Wound Therapy (Wound VAC).
- Evaluated ongoing medical necessity and insurance coverage requirements to support authorization approvals.
- Collaborated with physicians, caregivers, and interdisciplinary healthcare teams to address barriers to wound healing.
- Identified candidates appropriate for advanced wound care therapies.
- Developed and implemented workflow improvements that were adopted across the department.
- Successfully managed multiple territories and provider relationships while maintaining high service standards.
Pre-Operative Nurse, LVN - The Center for Special Surgery - San Antonio, Texas
(2008-04 - 2009-07)
- Performed comprehensive pre-operative assessments for pediatric, adult, and geriatric surgical patients.
- Assessed physical, emotional, and psychosocial needs while ensuring patient readiness for surgery.
- Administered medications, initiated IV therapy, and prepared patients for operative procedures.
- Collaborated with physicians and anesthesia providers to support safe surgical outcomes.
- Managed patient flow in a high-volume ambulatory surgery environment.
- Served on the Infection Control Committee and participated in surveillance, analysis, and reporting of healthcare-associated infections.
Unit/Medication Nurse, LVN - Laurel Ridge Treatment Center - San Antonio, Texas
(2007-02 - 2009-07)
- Provided nursing care for pediatric, adult, and geriatric behavioral health patients.
- Administered medications and therapeutic treatments while monitoring patient response and progress.
- Collaborated with physicians, therapists, and multidisciplinary teams to support individualized treatment plans.
- Maintained a safe therapeutic environment for patients experiencing acute mental health challenges.
- Assisted in launching the organization's outpatient Electroconvulsive Therapy (ECT) Program.
- Trained and mentored newly hired nursing staff.
Charge Nurse, LVN - Riverview Nursing & Rehabilitation - Boerne, Texas
(2006-11 - 2007-02)
- Directed daily clinical operations and supervised Certified Nursing Assistants and Medication Aides.
- Delivered direct patient care while ensuring compliance with state and organizational standards.
- Developed and maintained care plans, clinical documentation, and regulatory records.
- Assisted with staffing, scheduling, hiring activities, and departmental leadership responsibilities.
- Served as Interim Assistant Director of Nursing until permanent leadership was appointed.
Staff Nurse, LVN - Boerne Acute Care Center - Boerne, Texas
(2006-08 - 2006-11)
- Performed patient assessments, medication administration, diagnostic testing, and clinical documentation.
- Assisted physicians with examinations and minor procedures.
- Coordinated outpatient testing and specialty referrals.
- Supervised medical assistants and supported clinic operations.
- Organized and implemented community flu vaccination clinics.
