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Medical Nurse

Location:
Plano, Texas, United States
Salary:
open
Posted:
February 25, 2019

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Resume:

MELISSA ARMSTRONG, LVN

**** ******* ***** *****, ***** 75074 469-***-**** ac8lov@r.postjobfree.com

PROFILE

Twenty–two years’ experience as an LVN in the treatment of patients within the inpatient, hospice, home health, physician’s office, nursing home and managed care atmospheres. Six years’ experience reviewing and establishing medical necessity of Medicare Part A inpatient, Medicare Part B outpatient, DRG code validations, Medicare fraud cases, SNF, inpatient rehabilitation and outpatient claims at the redetermination level. Four years’ experience reviewing and establishing medical necessity of Medicaid Part B outpatient, pharmacy and wheelchair prior authorization requests. Seven months as a prior authorization supervisor. One year experience reviewing inpatient and outpatient request for private insurance.

EXPERIENCE

BLUE CROSS BLUE SHIELD OF TEXAS, RICHARDSON, TX 03/2018 to 10/2018

Utilization Review Medical Reviewer

•Identified appropriate benefits, eligibility, and expected length of stay for Blue Cross Blue Shield ERS participants requesting new treatments and/or procedures.

•Performed inpatient and outpatient medical necessity/utilization reviews as per Blue Cross Blue Shield ERS guidelines.

•Assessed services for ERS participants to ensure optimum outcomes, cost effectiveness and compliance with all regulations and guidelines.

Communicated with Medical Directors and providers to create solutions for any difficulties

in processing a request

•Demonstrated sound, ethical and independent decision-making consistent with Blue Cross Blue Shield ERS policies

MEDIX TEMPORARY AGENCY, DALLAS, TX/BLUE CROSS BLUE SHIELD OF TEXAS 09/2017 to 03/2018

Utilization Review Medical Reviewer

•Identified appropriate benefits, eligibility, and expected length of stay for Blue Cross Blue Shield ERS participants requesting new treatments and/or procedures.

•Performed inpatient and outpatient medical necessity/utilization reviews as per Blue Cross Blue Shield ERS guidelines.

•Assessed services for ERS participants to ensure optimum outcomes, cost effectiveness and compliance with all regulations and guidelines.

•Communicated with Medical Directors and providers to create solutions for any difficulties in processing a request

•Demonstrated sound, ethical and independent decision-making consistent with Blue Cross Blue Shield ERS policies

MOLINA HEALTHCARE- IRVING, TX 06/2013-09/2017

Utilization Management Supervisor 11/2016 to 09/2017

•Supervised a team of 12 LVNS, whose daily responsibilities include reviewing Medicaid authorizations

•Submitted daily assignments to LVNs

•Communicated with Medical Directors and providers to create solutions for any difficulties in processing a request

•Performed quality measures and monitored productivity standards

•Performed inpatient and outpatient medical necessity/utilization reviews as per TMHP, CMS and Molina guidelines

Utilization Management Care Review Clinician I 06/2013 to 11/2016

•Identified appropriate benefits, eligibility, and expected length of stay for members requesting new treatments and/or procedures.

•Performed inpatient, outpatient and pharmacy medical necessity/utilization reviews as per TMHP, CMS and Molina guidelines.

•Assessed services for Molina Members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulations and guidelines.

TRAILBLAZER HEALTH ENTERPRISES, DALLAS, TX 04/2007-06/2013

Medical Reviewer

•Performed accurate and timely Medicare Part A redetermination reviews and re-openings

•Demonstrated sound, ethical and independent decision-making consistent with CMS, Medicare and company protocols

•Interacted with Medical Director and outside departments to obtain policy supported decisions

•Delivered high-quality and educational written responses to the appellant when an unfavorable decision was rendered

•Developed job aids and work instruction for the Part A Redeterminations department

•Proficient with the use of InterQual, QIES extract and 3M to sustain the accuracy of inpatient, skilled nursing facility and DRG claim decisions

•Utilized the CMS website to process reviews in compliance with CMS and Medicare policies

•Reviewed Zone Program Integrity Contractor (ZPIC) and Medical Review probe cases

KINDRED ACUTE CARE HOSPITAL- DALLAS, TX 11/2006-04/2007

Acute Care Floor Nurse

•Provided care and support for patients undergoing wound complications, debilitating illnesses and ventilator support

•Completed assessments, initiated intravenous medication administrations, wound care support and oxygenation responses to the ventilator

•Evaluated responses to treatments and interacted with physician to adjust plan of treatment

SELF-EMPLOYED/STAY AT HOME MOTHER 10/2002- 11/2006

•Owned and managed an online and stand-alone consignment store

DALLAS DIAGNOSTICS ASSOCIATES- DALLAS, TEXAS 07/2001-09/2002

Clinical Nurse

•Supported the physician in a clinical setting from the intake process through follow up of plan of care

•Assisted physician with office procedures

#1963

GENTIVA HEALTHCARE- DALLAS, TEXAS 10/1998- 07/2006

Staff Nurse

• Provided care and support for patients within an inpatient, home health and hospice settings

• Monitored patient conditions and gave support to patient and family members

LIFE CARE CENTER OF PLANO- PLANO, TEXAS 10/1997- 10/1998

Clinical Nurse

• Provided care and support for patients within a long term care setting

• Monitored patient conditions and gave support to patient and family members

• Carried out physician orders and performed wound care as needed

• Completed assessments, monitored vital signs, administered medications

METHODIST MEDICAL CENTER- DALLAS, TX 10/1996- 10/1997

Clinical Nurse

•Carried out physician orders

•Provided care and support for patients undergoing cancer and end stage diseases

•Handled inpatient on oncology floor

•Completed assessments, initiated intravenous medication administrations, assisted with PICC line placements, wound care support and monitoring blood administration.

•Evaluated responses to treatments and interacted with physician to adjust plan of care

EDUCATION

•Graduate LVN program-North Central Texas College, Gainesville, TX-8/1996

•Basic Coding Certification

•Microsoft Word, Excel, Outlook, Fiscal Intermediary Standard System (FISS), InterQual, 3M Coding and Reimbursement system, QIES Extract, and DocFinity, UMK2, QNXT, SUM andMCG



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