Prior Authorization School Nurse
Resume:
**** ******* ***** *** *** Wexford PA ***** 585-***-**** ******************@*****.***
Melanie Schindler
Objective
Self-reliant, confident person of action with sound understanding of prior authorization reviews. Able to utilize my background in the nursing field to evaluate patient charts and apply the findings in the medical records to the appropriate guidelines and render a determination. Looking to further my career and development in the insurance industry.
Skills: Acute nursing, attention to detail, interpersonal skills, conflict resolution, adaptable, self-managed, quick learner, multitasking, proficient in Microsoft Office, team player, motivated
Certifications: PA licensed RN, NY licensed RN, CMCN
Work Experience
Centene Corp Rochester, NY June 2017-Current
Healthnet-TRICARE contract –Current
Excellus Contract- June 2017-November 2018
Maryland Physicians Care Contract- February 2018- November 2018
Utilization Review Nurse
Perform review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approve services or forward requests to the appropriate Physician or Medical Director with recommendations for other determinations
Complete benefit reviews, medical necessity reviews, and level of care reviews for requested services using policies and procedures clinical judgment and refer to Medical Directors for review depending on case findings
Collaborate with various staff within provider networks and case management team electronically or telephonically to coordinate member care
Educate providers on utilization and medical management processes
Provide clinical knowledge and act as a clinical resource to non-clinical team staff
Educate members on the medical management processes for their plan
Enter pertinent clinical information in various medical management systems
Maintain 98 percent or higher on all audit scores conducted by management and corporate
Other Duties
Process grievances and appeals in accordance with the process
Maintain timeframes on appeals and grievances
Assist in preparing fair hearing packets for all cases submitted to Envolve NY
Cover on call shifts on weekends in order to maintain timeframes on new and concurrent cases
Train new staff on system and processes of utilization management department
Assist with UM outpatient audits
Achievements
Key Contributor Award Winner x3
West Irondequoit School District Rochester, NY Sept. 2016- June 2017
School Nurse
Administer medications per MD order throughout the school day
Assess students’ injury and illness and provide recommendation
Substitute at schools throughout the district, as needed
Prepared documentation per school policy
Assist MD with evaluations of new students, sports physicals, and concussions
Work directly with nursing supervisor for the district to establish care plans
UPMC Passavant
Pittsburgh, PA
April 2015-April 2016
Professional Staff Nurse
Completed the education and have successfully been Charge RN on evening and night shift.
Demonstrated expertise in providing professional nursing services in the treatment and care of patients in reference to physician’s orders.
Handled medication administration, dressing changes, IVs and all other aspects of nursing care.
Documented success in coordinating total nursing care for patients.
Prepared chart notes and other documentation as require and participated in on interdisciplinary team.
Well versed in collecting and analyzing patients’ data
Committed to implement a plan of care for each patient to meet the need of patients
Expert in identifying variances in the plan of care and success of nursing interventions.
Adept at documenting care and identifying homecare needs.
Participated in bedside shift report to ensure patient safety.
Communicated plans of care with patient and family members.
Accomplishments: promoted to Professional Staff Nurse after 6 months of hire. Promoted to Charge RN after 10 months of hire
Hard Rock Café
Pittsburgh, PA
June 2011- April 2015
Server
Knowledgeable in all aspects of the restaurant, including the menu, wine, and beer
Meet clients expectations in a timely and effective manner
Effective and proven sales team member
Perform duties as directed during special events
Accomplishments: Spring 2011 awarded up sell team of the year, October 2011 Employee of the month
Education
Clarion University of Pennsylvania, Clarion, PA In progress
Bachelor’s of Nursing
UPMC Shadyside School of Nursing October, 2014
Clarion University of Pennsylvania, Clarion, PA
Major: Bachelor of Science in Mass Media, Arts, Journalism and Communications Studies May, 2011
Minor: Speech Communications
Concentration: Public Relations
References
Available upon request
Contact this candidate