Case Management Manager
Resume:
Melody K. Buck
Ruskin, Florida ****0
*******@*****.***
Profile
Motivated healthcare professional with over 20 years at the Cleveland Clinic seeking remote position utilizing my extensive experience in case management, utilization review and insurance denials/appeals to optimize benefits for payors and well as payees.
Experience
Cleveland Clinic Foundation, Cleveland OH
Denials/Appeals Specialist 2017-2022
●Reviewed denials and performed chart review to assess appropriate next steps
●Efficient and accountable: Personally responsible for an 80% overturn rate on the denials
●Summarized complex denials and escalated to Physician Adviser team for consideration
●Participated in weekly telephone conference with Physician Adviser team and payor to overturn denied cases
●Managed a variety of payor sources throughout the United States
Utilization Management 2012-2017
● Comprehensive chart review to determine appropriate level of care (LOC): Observation vs Inpatient
● Performed timely review of prospective, concurrent and retroactive records using evidence based guidelines
● Oriented new team members as well as provided on-going education and chart audits
● Proficient in MCG and Interqual criteria
Case Management
●Daily assessment of patients for post acute care needs and referrals to various levels of care
●Coordinated complex discharge planning to include multiple modes of transport across the United States
●Weekly care conferences with Medical Directors to discuss team collaboration and research projects
Summary
Functioned as a collaborative and creative problem solver in all the above areas, demonstrating leadership and instrumental in conflict resolution
Education/License/Certification
University of Akron, Bachelors of Science in Nursing
Nursing License, Registered Nurse, Ohio and Florida
The Commission for Case Manager Certification, Certified Case Manager (CCM)
REFERENCES AVAILABLE UPON REQUEST
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