Danae Brown

Performs clinical reviews needed to resolve and process appeals by reviewing medical records and clinical data to determine medical necessity for services in accordance with policies, guidelines, and National Committee for Quality Assurance (NCQA) standards.
• Prepares case reviews for Medical Directors by researching the appeal, reviewing applicable criteria, and analyzing the basis for the appeal
• Ensures timely review, processing, and response to appeal in accordance with State, Federal and NCQA standards
• Communicates with members, providers, facilities, and other departments regarding appeals requests
• Generates appropriate appeals resolution communication and reporting for the member and provider in accordance with company policies, State, Federal and NCQA standards
• Works with leadership to increase the consistency, efficiency, and appropriateness of responses of all appeals requests
• Partners with interdepartmental teams to improve clinical appeals processes and procedures to prevent recurrences based on industry best practices
• Performs other duties as assigned
• Complies with all policies and standards

• Implemented isolation precautions for high-risk patients, minimizing exposure risks to others within the healthcare environment.
• Optimized environmental cleaning procedures, resulting in decreased transmission of pathogens within the facility.
• Conducted regular audits of clinical practices related to infection control measures, identifying areas for improvement and providing targeted recommendations.
• Set clear policies to improve success of infection control measures in departments.
• Identified and mitigated unnecessary infection risks through regular reviews and procedural assessments.
• Coordinated successfully and with full compliance to prevent infections according to facility and Joint Commission standards.
• Enhanced patient outcomes by collaborating with multidisciplinary teams to address infection prevention concerns.
• Organized and led regular training sessions for staff members on infection prevention topics, ensuring continuous professional development opportunities.
• Investigated outbreaks and revamped control measures to prevent future incidents.

• Performed routine evaluations of each patient's status, needs, and preferences.
• Documented accurate and complete patient information to address patient problems and expected outcomes.
• Promoted a positive work environment among nursing staff through collaboration, open communication, and support.
• Coordinated with healthcare providers to schedule diagnostic tests for patients, expediting care plans as necessary.
• Educated patients and their families on disease management, medication administration, and at-home care techniques, empowering them to take control of their health.
• Collaborated with interdisciplinary team of healthcare and social service providers to address patients' needs through effective intervention and care planning.
• Assisted with admissions, appointments, transfers, and discharges.

• Managed patient care through closely monitoring respiration, blood pressure, and blood glucose levels.
• Prevented medication errors by meticulously reviewing physician orders and administering medications as prescribed.
• Worked with multidisciplinary team to carry out successful treatment plans for diverse acute and chronic conditions.
• Cared for wounds, provided treatments, and assisted with procedures.
• Facilitated effective communication between patients, families, and healthcare providers to ensure continuity of care during transitions between facilities or levels of care.
• Administered controlled narcotics, inserted IVs, and performed catheterizations.