Marcelyn Reed

• Complete medical necessity and level of care reviews for requested services using clinical judgment and refer to Medical Directors for review depending on case findings
• Provided clinical knowledge and acted as a clinical resource to non-clinical team staff
• Performed telephonic review of prior authorization requests for appropriate care and setting, following guidelines and policies, and approved services or forwarded requests to the appropriate Physician or Medical Director with recommendations for other determinations
• Verify member insurance and benefits
• Determine appropriateness and approve authorization request based on UM criteria, Medicare/CMS, Health Plan, and Milliman guidelines
• Recorded information in Claims Management system and communicated with the Claims Adjuster to process valid medical treatment requests for authorization per policy
• Communicated with requesting providers, service providers, claims adjusters and claimants via telephone and fax to request additional information
• Strengthened nursing practice through ongoing professional development and staying current on best practices in clinical review.
• Streamlined workflow processes by identifying gaps in clinical documentation and providing timely feedback to providers.
• Maximized efficiency within the department by organizing workload according to priority level, ensuring deadlines were met consistently.
• Collaborated with billing department to resolve discrepancies in claims processing, resulting in accurate reimbursement for services rendered.
• Demonstrated strong attention to detail by identifying discrepancies in medical records and collaborating with healthcare providers to rectify errors, ultimately enhancing the accuracy of patient information.
• Enhanced interdisciplinary collaboration through regular communication with physicians, case managers, and other healthcare professionals.
• Conducted regular audits of clinical documentation and provided constructive feedback to providers, leading to continuous improvement in the quality of patient care.

Identify inappropriate utilization of services/settings through the application of establish clinical criteria using Interqual and CMS guidelines for medical necessity

• Authorize requested medical services
• Prepare cases for physician review
• Authorize pre-authorization requests based upon evidence based UM criteria, coverage guidelines and benefit structure
• Generate organization determination notices in compliance with all regulatory standards for specific product line
• Expeditiously refer cases not meeting clinical guidelines/criteria to COM for review

• Provided preoperative, inter-operative, and post-operative care to patients
• Evaluated patient care needs, prioritized treatment and maintained patient flow
• Accurately documented all elements of nursing assessment, treatments, medications, discharge instructions and follow-up care
• Utilized strong assessment skills to determine necessary patient care
• Provided discharge instructions and teaching to patients being discharged home
• Utilized clinical expertise to remove sutures, administer medications and injections, administer IV therapy, test glucose levels, perform venipuncture, and provide wound care

• Assessed patient's condition planned and implanted patient care plans
• Treated wounds and provided Advanced Life Support
• Observed and recorded patient vital signs and intake and output
• Ensured that ventilators, monitors, and other medical equipment functioned properly
• Administered IV fluids, medications, injections, monitored glucose readings
• Responded to life-saving situations, using the LVN scope of practice, and hospital policy
• Provided education and support to both patients and their families