ANGELLA R. MELVILLE

• Conducts pre-certification, inpatient, out of network reviews to ensure compliance with applicable criteria.
• Issues approvals for inpatient stays that meet criteria based upon MCG guidelines.
• Responsible for requesting clinical information for concurrent review and additional clinicals if needed for authorization determination.
• Refer cases that doesn't appear to meet Inpatient criteria to Medical Directors for decision.
• Promotes a positive work environment as evidenced by demonstrating a professional,supportive attitude, and being receptive and responsive to changes in work assignment.

January 2022 - March 2022: Cross Trained in Prior Authorization Dept. for Outpatient procedures and DME.

• Conducted prior approval review for out - patient testing / procedures and in home durable medical equipments, as requested by physician or advanced practice providers.
• Provided approvals for Outpatient Procedures and DMEs per criteria guidelines, and refer to Medical Director when unable to approve request.
• Also exceeded expected numbers of prior auth reviews daily.

March 2022 - Present: Cross Trained in Medication Reconciliation.

• Using ACMP and Member 360 to search and find members discharge summary post Inpatient stay.
• Review discharge summary to ensure accuracy, verify medications, log appropriate summaries on spreadsheet, upload to Logato Nurses to further prepare for med reconciliation with physician or advanced practitioner.

April 2022- Present: Crossed Train in Hedis Quality Operations as Hedis Review Nurse

• Participated in medical record collection, request, and abstracted appropriate medical records assessing for assigned categories, and required clinical data elements for hedis reporting.
• Manage data abstractions, medical record review processes, identification of critical issues and process improvements to optimize measure results.

• Coordinate several health care aspects of individual patient in the acute setting
• Work with patients to assess their conditions and requirements along with the purpose of developingcareplanscustomizedtomeetthespecificpersonalneedsofpatients,alsomakeclinical decision for routine care
• Oversee the treatment of patients, monitors the delivery of nursing services, ensuring they conform to the patient's treatment plan and perform in a timely manner
• Arranges for the patient transfer to other acute, rehab or Assisted Living facilities
• Liaise with social workers to help in obtaining support services
• Perform initial and continued stay reviews with MCG, Interqual and Xsolis criteria, also request HMO authorizations as needed
• Oversee systems for identifying high risks patients through EMR and referrals
• Develop a detailed plan of action that meet patient needs, set goals, and find the necessary resources to meet those goals
• Collaborate with physicians and providers to assign correct patient statuses, ensuring compliance to CMS guidelines
• Developed and modified patient care plans and assisted interdisciplinary team in identifying client needs and goals to determine priorities of care.
• Analyzed patient responses to medications, therapies and variances in plans of care.
• Observed and documented patient factors such as diets, physical activity levels and behaviors to understand conditions and effectively modify treatment plans.
• Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
• Participated in evidence-based practice project implementation, nursing competency development and nursing simulation activities.

• Working onsite at hospital and managing home care referrals for patients at hospitals, clinics, facilities and the clinical team to arrange skill home care services for patients
• Manage the referral process and complete the initial paperwork for Nurses working in the field.
• Serve as a Liason between clients, families and healthcare team
• Prescreens potential referral to determine eligibility for CHHA program
• Consult with physician to initiate individualized Plan of Care also organizing and coordinating resources and services according to the patient needs
• Maintains frequent phone contact with physician, provider representatives, Field nurses and patients
• Obtaining authorization from HMO companies as needed, ordering DME supplies and arranging transportation upon discharge from hospital.
• Maintain working relationship with qualified referral resources.
• Conducted patient assessments and developed individualized treatment plans in coordination with other multidisciplinary healthcare professionals.
• Worked at least 24 hours per month as floor nurse on Med Surg unit to maintain clinical proficiency.

• Responsible for the coordination of member care services. Develop, implement and evaluate individualized care plans and outcome goals.
• Manage, negotiate collaborate with multidisciplinary teams, members and families, to provide efficient and prompt care
• Clinical review of field Nurses, Therapists and Social Worker findings, and collaborating home care service with physicians, HMO companies, and members.
• Initiate 485s documentation and ordering DME supplies
• Also lead case rounds weekly with interdisciplinary team
• Supervise Field Staff and review / document Field Nurses yearly evaluation
• Ensure that client receive the care they need and that they understand their medical condition and medications
• Provide referrals to community resources for assistance as needed.
• Educated and evaluated clinical and support staff regarding care quality management regulations and standards of care.
• Assessed healthcare needs and monitored effectiveness and progress plans to achieve desired outcomes.
• Offered leadership, support and clinical expertise within care management teams to achieve outcomes.
• Collaborate with hospital staff and families to assess and meet individual needs.
• Supervised team of six Registered Nurses working in the Community Visiting patients. Also assist with training newly hired nurses.

• Work directly with the providers and health plan Medical Director to facilitate quality service to members
• Responsibilities include collaborating long term care with clients, families and other members of the health care team, to ensure efficient and cost effective health care services and treatment.
• Also develop, implement and evaluate individualized client care plans, and revised according to health needs
• Responsible for providing timely referral according to members need
• Coordinate and manage all home care services
• Provide utilization review for preauthorization, concurrent and discharge service review
• Identification of referrals to the Medical Director for review
• Overseeing client's care and managing services according to what Medicaid allows.

• Assist physician during cardiac catheterization , angioplasty,pacemaker implantation and other interventional procedures
• Responsibilities include administering medications pre, during and post catheterization
• Monitoring patient status including EKG and vital signs and documenting clinical notes accordingly
• Preparation of patients can include taking the patient's vital signs, oxygen levels and heart rhythm before the physician examines the patient
• Ensure the patient's chart and records are updated and begin an intravenous line while preparing patients for a catheterization or cardiac procedure.
• Implemented medication, IV administration and catheter insertion
• Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
• Monitored patient condition by interpreting and tracking EKG readings, identifying irregular telemetry readings and updating team members on changes in stability or acuity.