Melanie Dees

Provide field-based case management services (within the worker's compensation industry) by utilizing professional judgement and discretion, applying professional processes, and adhering to Case Management Society of America (CMSA), ISYS, and customer guidelines.

Facilitate appropriate qualitative and timely medical care for injured workers by implementing prudent case management strategies, demonstrating proactive communication, and appropriate coordination with all parties to enable optimal recovery outcomes, including return to work determination, file progression towards Permanent and Stationary designation, and cost containment for the customer.

Facilitate timely claim resolution through proactive and professional communications, conducting case specific research, information analysis and providing appropriate advice, direction, and action plans to implement treatment and optimize realistic outcomes.

Manage a caseload of clinic patients and act as a liaison between the patient, physician, and other medical providers as well as insurance companies to ensure quality care for patients. Coordinate with appropriate staff and insurance payors to ensure smooth patient flow through the healthcare system. Create a comprehensive coordinated care plan for patients in the Chronic Care Management program. Assist patients in the management and education of chronic diseases. Transitional Care Management duties to include making hospital follow up appointment, educate patient on discharge instructions received at the hospital, review medications with the patient, and work to reduce hospital readmission.

Utilizes expertise in health promotion, chronic care management and motivational interviewing to teach and support Healthy Lives members' self-management of health and wellness. Assists Healthy Lives members to set realistic holistic health and wellness goals utilizing system tools and professional judgement. Work closely with members to understand disease specific related issues or interpret health risk assessment information to ensure members meet or exceed goals. Coordinates members' care team to assure obstacles to goals are removed including such activities as making appointments, assuring prescriptions are filled, directing care to physicians, specialists or other providers.

Perform utilization review of inpatient cases. Conduct clinical chart assessments. Discuss cases with treating physicians and other healthcare professionals. Participate in rounds with the Medical Director. Determine intervention needs. Identify delays in care. Initiate discharge plans and readmission prevention plans. Approve bed days for inpatient cases when applicable. Arrange alternative care services. Utilize MCG criteria. Gather clinical information to assess and expedite care needs. Facilitate timely and appropriate care. Participate in team meetings and educational discussion. Maintain appropriate and accurate documentation. Participate in staff meetings. This was a remote position.

Conduct first level prior authorization review determinations based upon application of approved medical necessity criteria, policies and procedures. Use of Milliman Criteria. Approve requested services that satisfy criteria requirements and refer to second level physician review when review conditions warrant such actions.

Nursing care related to those patients who are acutely ill and require extended hospitalization in an acute, inpatient environment. Use of the nursing process, IV therapy, medication administration, assisting physicians, airway and ventilator management; charge nurse duties. Orientation of new nursing staff as well as orientation of student nurse externs.

Assessment and education of individuals with chronic obstructive pulmonary disease and asthma in the tele-health setting.

Utilized critical thinking skills to prioritize nursing interventions based on patients'' acuity levels and individual needs.

Conducted thorough patient assessments to identify changes in condition, promptly notifying physicians and initiating appropriate interventions when necessary.

Administered medications safely according to established guidelines while closely monitoring for side effects or adverse reactions requiring intervention.

Enhanced patient satisfaction by providing compassionate, holistic nursing care that addressed physical, emotional, and spiritual needs.