SANDRA JAUREGUI-BAZA
LOS ANGELES
Summary
To support an organization that provides quality healthcare to a wide variety of patients. Aiming to leverage my vast experience throughout the healthcare spectrum.
Highly experienced bilingual Nurse Educator with a Master degree Science in Healthcare Management, vast healthcare experience and knowledge in healthcare management, health administration, managed care operations, risk and quality management, population health and patient focused care. Committed to facilitating the education and development needs of healthcare professionals to ensure clinical competency. Skilled in program development, implementation, and evaluation with ability to provide effective training and coaching on practices and policies. Strong organizational and analytical skills with a track record for guiding team to meet goals. Seeking to join an organization where I can contribute to the growth and success of the company.
Overview
23
23
years of professional experience
1
1
Certification
Work History
Bilingual Nurse Care Planner
SCAN Healthplan
11.2024 - Current
- Performed accurate documentation of patient assessments, interventions, and outcomes in compliance with regulatory standards.
- Promoted a safe and comfortable healing environment by addressing patient concerns promptly and professionally.
- Remained calm during high-stress, critical situations, demonstrating sustained focus and problem-solving in real-time.
- Educated patients on disease management, self-care techniques, and wellness strategies to improve long-term health outcomes.
- Improved patient satisfaction ratings by delivering compassionate and personalized care.
- Utilized strong clinical judgment in prioritizing patient needs during high-stress situations, ensuring optimal outcomes.
- Collaborated with interdisciplinary teams for optimized patient treatment plans and outcomes.
- Reduced medication errors through thorough double-checking of prescriptions and dosages.
- Provided emotional support to patients'' family members during critical incidents, strengthening overall trust in the healthcare team.
- Streamlined communication between patients, families, and healthcare providers to ensure comprehensive understanding of care plans.
- Communicated with healthcare team members to plan, implement and enhance treatment strategies.
- Educated family members and caregivers on patient care instructions.
Field Nurse Clinical Educator- Rare Disease
Momentum Life Sciences
06.2023 - 11.2024
- Responsible for utilizing professional skills and clinical experience to train patients and healthcare professionals on specific disease states and prescribed therapy regimen
- Engage with patients and healthcare professionals by building ongoing relationships, helping patients progress in their healthcare journey and facilitating behavior change utilizing motivational/behavioral change theories as a guide to patient empowerment
- Responsible for training within multiple formats including live, virtual, and telephonic to a variety of audiences including, but not limited to patients, office staff, caregivers, and pharmacists
- Build relationships with healthcare providers and office staff; foster an open dialogue between patient and health care provider
- Act as a community liaison
Medicare Risk Adjustment and Quality Program Consultant
Optum
04.2018 - 10.2023
- Collaborate with Health Plans, Medical Groups, Independent Practitioner Associations (IPAs) and Providers to improve quality of care for members
- Facilitate provider discussions focused on the importance of comprehensive Annual Wellness visits and assessment of chronic conditions year over year
- Utilizing data analysis, identify and target providers who would benefit from coding, documentation and quality training and resources Educate providers on how to improve their Risk Adjustment Factor (RAF) scores, which measure their patients' health status
- Establish positive, long-term, consultative relationships with physicians, medical groups and IPAs
- Develop comprehensive, provider-specific plans to increase their quality and RAF performance and improve their coding specificity
- Provide training to provider groups on Medicare Advantage and risk adjustment and Quality Measures
- Coordinate large and small group training sessions in collaboration with the Optum Coding Trainers and Clinical staff
- Collaborate with doctors, coders, facility staff and a variety of internal and external personnel on a wide scope of Risk Adjustment education efforts
- Coordinate risk adjustment chart reviews with capitated and risk share providers
Med-Surg Registered Nurse
LAC+USC Medical Center
12.2022 - 07.2023
- Perform initial patient assessments and work with physicians to plan, implement, and evaluate plans of care for patients of all ages
- Record patients’ medical history, vital statistics, and test results in electronic and physical medical charts
- Observe patients and actualize nursing interventions to expedite healing and recovery after surgery
- Utilize clinical expertise and implement care plan according to orders such as suture removal, catheter placement, oral, intramuscular an IV therapy, venipuncture, and wound care
- Educate patients and caregivers on diagnosis, treatment options, and disease process, and self-management
- Provide comprehensive instruction on discharge plans to sustain continuity of care upon discharge and drive recovery goals
Director of Network Management and Provider Relations
Regal Medical Group
12.2011 - 03.2018
- In collaboration with the Vice President of Regional Operations, identify opportunities for the development and growth of the Greater Los Angeles region
- Coordinate and perform projects/activities as delegated by organization committees and Vice President of Regional Operations
- Oversee Network Management staff
- Daily interaction with Network Managements operational functions
- Contract negotiations on various levels including professional and ancillary contracting
- Analyze contract rates and proposals
- Resolve provider grievances and appeals in accordance with contractual requirements and corporate policy
- Coordination of all provider education initiatives
- Ensure contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as required by contracting HMOs
- Internal contract liaison for Claims, Customer Service and Utilization Management Departments
- Develop and Implement regional policies and procedures
- Facilitate quarterly Joint Operations Meetings with contracted providers and health plans
- Oversight of database maintenance and accuracy through use of audits
- Ensure accurate and timely data reporting requirements are being met including eligibility and capitation reports, risk sharing, claims timeliness, pharmacy utilization, bed days utilization, encounter data and audit compliance
- Responsible for the daily operational functions and fiscal performance of the department and networks within the region, contractual compliance and provider negotiations, marketing, development, provider relations and provider education
- Know and follow the Employee Handbook polices and procedures
- Maintain patient confidentiality so that HIPPA compliance is observed at all times
Chronic Care Management Coordinator
Regal Medical Group
06.2006 - 08.2010
- Worked under a Nurse Case Manager to follow up on SNF and Hospital discharged patients
- Facilitated post- discharge needs such as DME, Home Health Care, Physical Therapy, Post-op or Post- Discharge physician follow up appointments
- Followed up regularly with assigned Chronic Condition patients ( DM, CHF, ESRD…etc)
- Researched Transition of care (TOC) cases
- Assisted with finding alternatives for non compliant patients
- Facilitated Chemotherapy drug orders for assigned cancer patients
Utilization Management Coordinator
Regal Medical Group
06.2002 - 06.2006
- Screened authorization request forms for proper ICD-9 and CPT coding
- Reviewed and worked with physician offices to gather medical necessity criteria for authorization request forms
- Verified Benefits and crossed referenced the Division of Responsibility Charts (DOFR) for referral requests
- Reviewed Milliman and Robinson, Interqual and Medicare guidelines, when applicable, and presented to a Medical Director for review
Education
B.S. - Nursing, Public Health Nurse
California State University, San Marcos
San Marcos, CA10.2023
Associate Degree - Nursing
Mount Saint Mary’s University
Los Angeles, CA05.2022
Certified Risk Adjustment Coder - undefined
American Academy of Professional Coders (AAPC)
01.2019
M.S. - Health Care Management
California State University, Los Angeles
Los Angeles, CA12.2014
B.A. - Anthropology
California State University, Los Angeles
Los Angeles, CA06.2009
Medical Assistant Diploma - undefined
Bryman College
Reseda, CA04.2001
High School Diploma - undefined
Birmingham High School
Lake Balboa, CA06.2000
Skills
Bilingual: English /Spanish
Public Health Nurse
Over 20 years in Healthcare Management Experience
Certified Risk Adjustment Coder
Broad understanding of NCQA & Interqual Guidelines
Extensive experience with managed healthcare
Detail oriented
Problem solver
Certification
Certified risk adjustment Coder
Public Health
Languages
Spanish
Native or Bilingual
Timeline
Bilingual Nurse Care Planner
SCAN Healthplan
11.2024 - Current
Field Nurse Clinical Educator- Rare Disease
Momentum Life Sciences
06.2023 - 11.2024
Med-Surg Registered Nurse
LAC+USC Medical Center
12.2022 - 07.2023
Medicare Risk Adjustment and Quality Program Consultant
Optum
04.2018 - 10.2023
Director of Network Management and Provider Relations
Regal Medical Group
12.2011 - 03.2018
Chronic Care Management Coordinator
Regal Medical Group
06.2006 - 08.2010
Utilization Management Coordinator
Regal Medical Group
06.2002 - 06.2006
B.S. - Nursing, Public Health Nurse
California State University, San Marcos
Associate Degree - Nursing
Mount Saint Mary’s University
Certified Risk Adjustment Coder - undefined
American Academy of Professional Coders (AAPC)
M.S. - Health Care Management
California State University, Los Angeles
B.A. - Anthropology
California State University, Los Angeles
Medical Assistant Diploma - undefined
Bryman College
High School Diploma - undefined
Birmingham High School
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