Margaret F. Hammond
Abingdon,MD
Summary
Dynamic Senior Clinical Appeals Nurse Analyst with a proven track record at CareFirst BlueCross Blue Shield, excelling in clinical appeal processes and regulatory compliance. Adept at training staff and fostering team collaboration, I leverage critical thinking to drive effective case resolutions and enhance healthcare documentation, ensuring optimal outcomes.
Overview
45
45
years of professional experience
Work History
Senior Clinical Appeals Nurse Analyst
CareFirst BlueCross Blue Shield
Baltimore, Maryland
11.2018 - 01.2026
- Reviewed cases with medical directors; escalated high-risk issues to leadership for resolution.
- Applied comprehensive understanding of appeals, grievances, and reconsideration processes to support effective case resolutions.
- Created precise documentation and database entries that articulated decision rationale and aligned with medical policy criteria.
- Completed preparation of regulatory cases and maintained professional communication with regulatory agencies.
- Mentored and trained associates, fostering skill development and enhancing overall team capabilities.
Hospital Transition Coordinator
CareFirst BlueCross Blue Shield
Baltimore, Maryland
05.2013 - 11.2018
- Triaged patients efficiently into appropriate levels for care transitions program, ensuring timely access to necessary services.
- Collaborated with facilities to facilitate safe discharges aligned with member needs, promoting continuity of care.
- Engaged patients in active participation within care transitions initiatives.
- Coordinated essential interventions tailored to member requirements.
- Organized and streamlined referrals for case management, mental health services, and medication reconciliation, enhancing patient support.
- Communicated professionally with internal and external physicians, providers, and members.
Emergency Department RN Case Manager
John's Hopkins Bayview Medical Center
Baltimore, Maryland
01.2009 - 01.2018
- Applied interqual and milliman criteria for ED, observation, and admission reviews to ensure appropriate patient classification.
- Collaborated with attending physicians on placement, insurance authorizations, and transfer of emergency room patients needing psychiatric care, enhancing continuity of care.
- Coordinates the management of social issues that impact patient classification, discharge from the ER, and ongoing medical management of patient care needs.
- Communicated with patients, families, and health care providers to promote health and manage illnesses, focusing on quality and cost-effective solutions.
- Promoted customer service excellence in all communications with healthcare team and patients.
Senior Utilization Review Specialist
CareFirst BlueCross Blue Shield
Baltimore, Maryland
01.2003 - 05.2013
- Demonstrated Expertise in the Application of Milliman Criteria for Inpatient Reviews.
- Adhered to department policy on utilization issues, identified and documented service delays, and generated denial letters after medical director review.
- Coordinates and communicates health care decisions and plans with internal/external customers/providers.
- Provided proactive discharge planning, assisting patients with needs and offering alternative options.
- Conducted training on best practices for peers, fostering improved team performance.
- Ability to document in a database and use Electronic Medical Records.
- Identified potential fraud cases to designated supervisors for investigation to SI Unit.
Emergency Department Nurse
Upper Chesapeake Medical Center
Baltimore, Maryland
01.2003 - 12.2008
- Triage and managed clinical emergencies effectively, ensuring timely and appropriate patient interventions.
- Directed and delivered comprehensive patient care across all age groups, adhering to emergency department standards.
- Assessed and documented physical, psychological, and discharge planning needs of admitted patients to facilitate continuity of care.
Triage Call Center Nurse
Magellan Nurse Access Line
Baltimore, Maryland
01.2002 - 01.2003
- Evaluated purpose and severity of incoming calls using approved clinical guidelines.
- Managed urgent calls requiring 911 assistance in accordance with established protocols.
- Delivered triage health information via telephone to address healthcare questions and concerns.
Contractual Staff Nurse
Nurse Corps Occupational Services
Baltimore, Maryland
01.2001 - 01.2002
- Delivered emergent care and first aid to injured employees, ensuring rapid medical response.
- Trained and supervised first aid and rescue team, enhancing emergency preparedness.
- Compiled reports according to field operations manual, contributing to safety and compliance.
Director of Medical Support/Staff Nurse
Patient First Medical Center
Baltimore, Maryland
01.1994 - 01.2001
- Delivered emergent care and coordinated follow-up services to enhance patient recovery.
- Conducted patient assessments and triaged cases per physician guidelines for timely intervention.
- Supervised medical and clerical staff in urgent care settings to align operations with directives from medical director.
Emergency Room Staff Nurse
Bon Secours Hospital
Baltimore, Maryland
01.1990 - 01.1994
- Coordinated patient care and team responses during clinical emergencies as charge nurse.
- Assessed and documented patients' physical, psychosocial, and educational needs for comprehensive care plans.
- Delivered direct patient care to community patients in accordance with emergency department protocols.
Emergency Room Nurse/IV Therapy Nurse
Maryland General Hospital
Baltimore, Maryland
01.1983 - 12.1989
- Delivered direct patient care in emergency room, ensuring timely and effective treatments.
- Administered IV therapy while monitoring effectiveness and patient responses.
- Provided skilled nursing and education according to policy, improving patient understanding and compliance.
Trauma Room Nurse/ MICU Staff Nurse
University of Maryland Hospital
Baltimore, Maryland
02.1981 - 01.1983
- Provided direct patient care for critically ill patients in acute medical intensive care unit and trauma center, facilitating optimal recovery outcomes.
Education
Diploma Registered Nurse - Baltimore, MD
Maryland General Hospital School of Nursing
Baltimore, MD01-1981
Skills
- Clinical appeal processes
- Utilization review
- Regulatory compliance
- HIPAA protocol adherence
- Policy compliance
- Case management
- Electronic medical records
- Healthcare documentation
- Critical thinking
- Training staff
- Team collaboration
- Effective communication
Certifications Skills
- IV Therapy Certified
- ENA Trauma Nurse Certified
- BLS Certified
Timeline
Senior Clinical Appeals Nurse Analyst
CareFirst BlueCross Blue Shield
11.2018 - 01.2026
Hospital Transition Coordinator
CareFirst BlueCross Blue Shield
05.2013 - 11.2018
Emergency Department RN Case Manager
John's Hopkins Bayview Medical Center
01.2009 - 01.2018
Senior Utilization Review Specialist
CareFirst BlueCross Blue Shield
01.2003 - 05.2013
Emergency Department Nurse
Upper Chesapeake Medical Center
01.2003 - 12.2008
Triage Call Center Nurse
Magellan Nurse Access Line
01.2002 - 01.2003
Contractual Staff Nurse
Nurse Corps Occupational Services
01.2001 - 01.2002
Director of Medical Support/Staff Nurse
Patient First Medical Center
01.1994 - 01.2001
Emergency Room Staff Nurse
Bon Secours Hospital
01.1990 - 01.1994
Emergency Room Nurse/IV Therapy Nurse
Maryland General Hospital
01.1983 - 12.1989
Trauma Room Nurse/ MICU Staff Nurse
University of Maryland Hospital
02.1981 - 01.1983
Diploma Registered Nurse - Baltimore, MD
Maryland General Hospital School of Nursing