Kerry Weldon

• Conducted comprehensive reviews of medical records to identify billing discrepancies and ensure compliance.
• Collaborated with coding, billing, and clinical teams to address issues related to claim denials and underpayments.
• Assessed clinical documentation for accuracy and adherence to coding standards.
• Applied diagnostic and procedural coding expertise for accurate claim submissions including ICD-10, CPT, and HCPCS.
• Evaluated service appropriateness based on clinical guidelines to determine medical necessity.
• Utilized systems such as Microsoft, Insinq, NCompass, Quadient, and Pareo for efficient operations.
• Drafted concise letters for providers to facilitate clear communication.
• Formulated effective appeal strategies to manage denied claims.

• Implement the prospective, concurrent and retrospective review processes that are consistent with established industry and corporate standards and are within the Medical Review Clinician’s professional discipline.

• Effectively function in accordance with applicable state, federal laws and regulatory compliance.

• Implement all retrospective reviews according to accepted and established criteria (InterQual), as well as other approved guidelines and medical policies.

• Promote quality and efficiency in the delivery of retrospective review services.

• Respect the member’s right to privacy, sharing only information relevant to the member’s care and within the framework of applicable laws.

• Practice within the scope of ethical principles.

• Identify and refer members whose healthcare outcomes might be enhanced by Case Management or Condition Management interventions.

• Employ collaborative interventions which focus, facilitate, and maximize the member’s health care outcomes.

• Develop and sustain positive working relationships with internal and external customers.

• Utilize outcomes data to improve ongoing care management services.

• Delivered 24/7 telephonic triage and health education to Highmark members as part of the Blues On Call program.
• Assessed symptoms, provided evidence-based next steps, and determined appropriate levels of care using clinical protocols.
• Provided chronic condition coaching (e.g., diabetes, hypertension, obesity) to support self-management and reduce avoidable ER visits.
• Collaborated with case managers, physicians, and behavioral health teams to support integrated care.
• Accurately documented all calls in real-time, ensuring compliance with NCQA, CMS, and internal QA standards.
• Maintained high member satisfaction scores by offering compassionate and clear health information.

• Provided telephonic and virtual health coaching to insured members with chronic conditions (e.g., diabetes, hypertension, obesity), driving a 20% improvement in program adherence.
• Educated members on preventive care and wellness strategies using evidence-based guidelines and motivational interviewing techniques.
• Partnered with care coordinators, providers, and behavioral health teams to ensure integrated care planning.
• Utilized risk stratification tools and EMRs to assess needs and deliver personalized interventions.
• Documented interactions and outcomes in compliance with HIPAA and insurance regulations.

• Provided direct care to a diverse population of patients with acute and chronic cardiac and pulmonary conditions, including CHF, MI, COPD, pneumonia, and arrhythmias.
• Monitored telemetry for up to [6] patients, promptly identifying changes in cardiac rhythms and initiating interventions per ACLS protocol.
• Collaborated with respiratory therapists to manage BiPAP, CPAP, and oxygen therapy.
• Administered cardiac and respiratory medications, including beta-blockers, anticoagulants, diuretics, and nebulizers.
• Educated patients and families on disease management, medication adherence, lifestyle modifications, and discharge instructions.
• Participated in interdisciplinary rounds to ensure coordinated, patient-centered care.
• Recognized for strong critical thinking and calm demeanor in high-pressure situations.