Megan Joles
San Antonio,TX
Summary
Detail-oriented RN with extensive experience in case management and clinical research seeking a Senior Pipeline Medical Science Liaison role to apply my clinical expertise, strong problem-solving skills, and ability to collaborate with healthcare professionals in supporting the development and delivery of cardiovascular and metabolic treatments. Known for building relationships, managing complex clinical data, and improving patient outcomes through effective communication and process optimization.
Overview
10
10
years of professional experience
Work History
Utilization Manager
Community First Health Plans
San Antonio, TX
04.2024 - Current
- Conduct thorough reviews of patient records to ensure that services billed under Medicaid are medically necessary, appropriate, and in compliance with state and federal guidelines.
- Ensure that treatments, tests, and procedures align with clinical guidelines, payer policies, and best practices.
- Analyze Medicaid claims and service utilization data to identify trends, cost-saving opportunities, and areas for improvement.
- Educate healthcare providers and staff on Medicaid eligibility requirements, covered services, and billing practices.
- Conducted concurrent reviews to identify any inappropriate use of resources as well as duplication of services.
Case Manager
Acara Healthcare
San Antonio, TX
11.2023 - 04.2024
- Recertify pediatric patients to ensure the continuation of home health services and therapies.
- Routinely review medical records, and ensure compliance to avoid interruption of services.
- Obtain prior authorization from insurance companies.
- Ensure that medical records meet insurance criteria for services needed.
- Educated clients and their families about their rights and available community resources.
- Facilitated communication between clients, families, caregivers, social services and other agencies to ensure client needs were met.
Case Manager/Utilization manager
WellMed
San Antonio, TX
09.2021 - 11.2023
- Created prior authorizations utilizing MCG/DRG criteria for SNF, ARU, LTAC, transportation, and DME.
- Reviewed and evaluated medical records, and ensured adherence to the Centers for Medicare & Medicaid Services (CMS) guidelines.
- Liaison between infusion, home health, SNF, ARU, and long-term acute care facilities.
- Coordinated and provided managed care for members with complex needs.
- Led weekly meetings to strategize member progress and interventions.
- Subject Matter Expert (SME) for SNF, ARU, and LTAC prior authorizations.
Mother Baby Registered Nurse
GiaMed Staffing
San Antonio, TX
03.2019 - 09.2021
- Collaborated and monitor clinical data to optimize client outcomes.
- Provided personalized care for clients with diverse disease processes.
- Trained new staff on unit policies and standard operating procedures (SOPs).
- Offered post-surgical care guidance and support.
- Developed individualized care plans and goals, and educate clients on home care.
- Collaborated within a team environment to prioritize client safety.
Mother Baby Registered Nurse/Charge Nurse
HCA Hospital
San Antonio, TX
01.2017 - 02.2019
- Delivered postpartum care for mothers and newborns, including recovery and breastfeeding support
- Developed and implemented individualized care plans in compliance with regulatory standards
- Administered medications, coordinated unit operations, and ensured adherence to protocols
- Delegated tasks based on staff competency and workload; mentored nursing staff
- Facilitated communication between staff, patients, and families to enhance care coordination
Mother Baby Registered Nurse
Central Texas Medical Center
San Marcos, TX
02.2015 - 01.2017
- Educated and empowered mothers on newborn care and postpartum self-care.
- Collaborated within interdisciplinary teams for optimal patient outcomes.
- Responded to potential complications and emergencies.
- Foster collaboration with specialists for enhanced care.
Education
Bachelors of Science - Nursing
Hallmark University
San Antonio, TX04-2024
Associate degree of Science - Nursing
Hallmark University
San Antonio, TX12.2014
Skills
- Clinical documentation and compliance
- Process Improvement and Problem Solving
- Effective communication
- Quality Assurance
- Collaborative teamwork
- Adaptability and organization
- Technical Proficiency: EMR Systems: Tenet, Epic, Essentris, Meditech; Microsoft Office Suite: Word, Excel, PowerPoint, Outlook; Operating Systems: Windows, Mac
Timeline
Utilization Manager
Community First Health Plans
04.2024 - Current
Case Manager
Acara Healthcare
11.2023 - 04.2024
Case Manager/Utilization manager
WellMed
09.2021 - 11.2023
Mother Baby Registered Nurse
GiaMed Staffing
03.2019 - 09.2021
Mother Baby Registered Nurse/Charge Nurse
HCA Hospital
01.2017 - 02.2019
Mother Baby Registered Nurse
Central Texas Medical Center
02.2015 - 01.2017
Bachelors of Science - Nursing
Hallmark University
Associate degree of Science - Nursing
Hallmark University
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