Hi, I’m
Shyre C. Edrosa
Caloocan City,00
Summary
Experienced in patient care management, team leadership, and clinical coordination. Leveraging critical thinking and organizational skills to improve patient outcomes and streamline healthcare processes. Deep understanding of compliance standards and effective communication techniques for optimal patient care delivery.
Overview
16
years of professional experience
1
Certification
Work History
Carelon Global Solutions
NURSE CLINICAL COORDINATOR (USRN)
01.2020 - Current
Job overview
- Company Overview: Formerly known as Legato Health Technology Inc
- Responsible for HEDIS medical record identification and abstraction
- Primary duties may include, but are not limited to: Conducts medical record abstraction audits of medical records
- Serves as a resource and subject matter expert on HEDIS quality reviewer processes
- Conducts over-reads on HEDIS records for compliance against HEDIS Technical Specifications and ensures feedback is considered
- Identifies patterns and interprets clinical handwriting of providers
- Gathers and analyses data, and organizes and writes reports
- Educates providers on HEDIS specifications and medical record documentation via various mediums such as HEDIS Encounter Portal Submission Tool, Hybrid Review Tool, HEDIS reference material development, and any other educational pieces for Provider relations, etc
- Provides feedback to providers via the HEDIS Encounter Submission Tool for medical records and ensures feedback is considered
- Reviews HEDIS Encounter Portal submissions for Star Metrics within given set deadlines
- Works on projects as assigned
- Develops expertise in the requirements and parameters of mandated HEDIS performance measures on an annual basis
- Requires a degree in nursing, healthcare administration, or related field; 2 years of clinical experience including medical record noting, auditing, and data abstraction, and HEDIS experience; or any combination of education and experience, which would provide an equivalent background
- Current, unrestricted clinical license appropriate to field of specialty (RN/LPN) required
- Active state license required
- 2 years of experience as a HEDIS medical chart reviewer preferred
- Knowledge of population health (epidemiology) and quality improvement concepts and intervention
- Experience with daily operations in a clinical, managed care, hospital care setting including working with provider systems and medical providers required
- Formerly known as Legato Health Technology Inc
Access Healthcare Services
Prior Authorization Representative
10.2018 - 01.2020
Job overview
- Conduct administrative outbound and clinical outbound calls for clinical review
- Provides quality customer service through interaction with payer, administrative staff and others
- Initiate an order request from the provider
- Provide confidential information to the Clinical Review nurse
Shearwater Health
Client Service Representative
02.2012 - 04.2018
Job overview
- Company Overview: HCCA Health Connections Inc
- Conduct administrative intake and scripted clinical intake calls for clinical review
- Provides quality customer service through interaction with providers, administrative staff and others
- Collects and enters confidential information ensuring the highest level of confidentiality in all areas
- Refers all calls to the Clinical Reviewer or Supervisor per guidelines
- Maintains written documentation according to HH’s documentation policy
- Provides ongoing telephonic support to providers and staff related to HH’s Clinical Review process
- Assists in the orientation and training of new Client Service Representatives in department procedures, protocols and administrative tasks
- Provide administrative support to the Clinical Review Department if needed
- Carries out other projects and responsibilities as assigned
- Participates and understands scope of responsibility pertaining to ongoing QI Projects
- HCCA Health Connections Inc
Earthlink Care Health Services
PRIVATE DUTY NURSE
01.2010 - 12.2010
Job overview
- Provides quality Nursing care to geriatric patient
- Provide proper documentation that will relay to co-worker and the MD’s if needed
- Monitor vital signs of patient and document properly
- Ensure that the medication will be given on time
- Assist the patients in Activities of daily living
JOB1 Global Inc.
MARKETING ASSISTANT/DATA ANALYSIS (Front desk officer)
06.2009 - 12.2009
Job overview
- Provides client information regarding the services offered by the company
- Data Encoding
- Takes orders from the supervisor
- Answers phone calls
- Assists clients concern
Education
Our Lady of Fatima UniversityQuezon City, Metro Manila, Philippines
Bachelor of Science from Nursing
03-2009
Skills
- Home health nursing
- Basic life support
- HIPAA compliance
- Clinical documentation
- Clinical assessment
- Patient care coordination
- Healthcare management
- Quality improvement
- Geriatric nursing
- Rehabilitation nursing
- Nursing leadership
- Patient confidentiality
Certification
- Basic Life Support Certification (BLS)
- [Name of Certification] [Issuing Organization] [Year Month]
Tavelling
I'm passionate about traveling as it brings balance and enrichment to my life. Last year, I had the opportunity to explore three domestic destinations and one international location, which broadened my understanding of diverse cultures. A highlight of my travels was visiting El Nido, Palawan. The breathtaking beauty of the islands and the chance to connect with nature left me in awe. This experience not only revitalized me but also sparked a desire to continue exploring and discovering new places.
Languages
English
Intermediate (B1)
Timeline
NURSE CLINICAL COORDINATOR (USRN)
Carelon Global Solutions
01.2020 - Current
Prior Authorization Representative
Access Healthcare Services
10.2018 - 01.2020
Client Service Representative
Shearwater Health
02.2012 - 04.2018
PRIVATE DUTY NURSE
Earthlink Care Health Services
01.2010 - 12.2010
MARKETING ASSISTANT/DATA ANALYSIS (Front desk officer)
JOB1 Global Inc.
06.2009 - 12.2009
Our Lady of Fatima University
Bachelor of Science from Nursing
Similar Profiles
MADHAVI CHENGATUMADHAVI CHENGATU
Business Analyst at Carelon Global Solutions: Summitworks Technologies and UST GLOBALBusiness Analyst at Carelon Global Solutions: Summitworks Technologies and UST GLOBAL
Vijay SharmaVijay Sharma
Delivery Manager at Carelon Global SolutionsDelivery Manager at Carelon Global Solutions
Wenstina DsouzaWenstina Dsouza
Senior Software Engineer at Carelon Global SolutionsSenior Software Engineer at Carelon Global Solutions