Melaney Malone
Lebanon,TN
Summary
Organized and dependable nurse successful at managing multiple priorities with a positive attitude. Willingness to take on added responsibilities to meet team goals. Motivated to learn, grow and excel in a Manage Care Organization.
Overview
11
11
years of professional experience
Work History
Clinical Appeals Nurse
Parallon
, TX
12.2021 - Current
- Compose clinical appeal letters to send to payers for denial reconsiderations utilizing documentation, contract language, or voice recordings as applicable
- Responsible for investigating and processing and medical necessity appeals requests from members and providers.
- Present a concise medical summary within each appeal based on support from the medical record Demonstrate understanding of use of all Medical Necessity software, including but not limited to InterQual©
Clinical Claim Nurse Reviewer
Optum Care/LHI
La Crosse, WI
06.2020 - 11.2021
- Reviewed and documented relevant information into data system applications.
- Managed large volume of medical exams on daily basis.
- Evaluated all evidence with ultimate goal of creating positive outcomes for Veterans claims.
- Documented all information gathered field and uploaded data to company database for efficient processing using VA guidelines.
Telephone Triage Nurse
NCCM
Nashville, TN
06.2018 - 06.2021
- Adhered to standardized protocols to assess and formulate a plan of care
- Counseled patients via telephone according to established guidelines and protocols, advising on provider-established plans of care.
- Triaged patients by reviewing symptoms and advising on best treatment plan to facilitate patient care while minimizing impact on healthcare system.
HEDIS Review Nurse
Medlinks Staffing
Antioch, CA
12.2019 - 03.2020
- Review and abstraction of medical record data for multiple HEDIS Hybrid measures
- Entry data into HEDIS software system
- Maintained historical reference by abstracting and coding clinical data such as diseases, operations, procedures and therapies with standard classification systems.
Data Collection Nurse
The Judge Group
Brentwood, TN
10.2018 - 01.2019
- Retrieval,review, and abstraction of medical record data required for multiple HEDIS hybrid measures.
- Entering data into a HEDIS software system
- Collaborate with clinical and non-clinical staff regarding provider scheduling and on-site medical record retrieval.
Registered Nurse
St Thomas West Hospital
Nashville, TN
03.2012 - 04.2018
- Monitored patients' respiratory status and ventilator operation and made adjustments to promote stabilization.
- Assessed and managed various patient treatments for numerous patient diagnoses from sepsis to acute respiratory distress.
- Collaborated with physicians to quickly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
- Guided patients, caregivers and family members on plans of treatment and helpful resources available locally to support care.
Education
Associate Degree In Nursing - Nursing
Breckinridge College Of Nursing
Nashville, TN09.2014
Bachelor Of Science - Nursing
Chamberlain University
Downers Grove, IL10.2020
Skills
- Hedis abstractor
- Proficient in Microsoft Word, Excel, Outlook
- Medicare and Medicaid experience
- Metrics analysis
- Compliance Monitoring
- Practice Standards Development
- Patient Record Review
- Analytical and Critical Thinking
- Denial Appeals Process
Additional Information
Multistate Compact Nursing License
Hold active Registered Nursing License in the state of
Alaska, Nevada, and California
Timeline
Clinical Appeals Nurse
Parallon
12.2021 - Current
Clinical Claim Nurse Reviewer
Optum Care/LHI
06.2020 - 11.2021
HEDIS Review Nurse
Medlinks Staffing
12.2019 - 03.2020
Data Collection Nurse
The Judge Group
10.2018 - 01.2019
Telephone Triage Nurse
NCCM
06.2018 - 06.2021
Registered Nurse
St Thomas West Hospital
03.2012 - 04.2018
Associate Degree In Nursing - Nursing
Breckinridge College Of Nursing
Bachelor Of Science - Nursing
Chamberlain University