MELANIE EVERETT
Bedford,VA
Summary
Compassionate Registered Nurse with over 30 years in clinical care and care coordination. Expertise in facilitating safe transitions of care, conducting clinical assessments, and improving patient outcomes through collaboration with multidisciplinary teams. Seeking to contribute extensive knowledge in an RN Care Coordinator position.
Overview
1
1
Certification
17
17
years of professional experience
Work History
RN Care Coordinator
Optum Health
12.2021 - Current
- Conducted comprehensive clinical assessments and reviews to identify and recommend appropriate levels of care, enhancing patient outcomes.
- Coordinate care with physicians, case managers, rehabilitation teams, hospitals, skilled nursing facilities, patients, and families.
- Facilitate transitions of care and ensure continuity across post-acute settings.
- Completed Continuity of Care (COC) referrals and facilitated post-discharge follow-up to ensure seamless transitions and adherence to care plans.
- Identify barriers to recovery and implement interventions to improve patient outcomes.
- Monitor patient progress and communicate clinical updates to healthcare stakeholders.
- Supported quality initiatives aimed at reducing unnecessary readmissions and enhancing patient satisfaction through proactive care coordination.
- Review medical records and clinical documentation for completeness, accuracy, and compliance.
- Participated in remote CMCC operations
SICC- On-site
NaviHealth, Inc.
Brentwood, USA
06.2018 - 12.2021
- Conducted clinical reviews for Medicare and managed care members, ensuring compliance and quality of care.
- Collaborated with interdisciplinary teams to develop and implement patient-centered care plans.
- Assessed discharge readiness and coordinated safe transitions to appropriate post-acute settings.
- Evaluated clinical documentation to support utilization management and quality outcomes.
- Investigated and escalated patient care concerns affecting treatment progression or patient safety.
- Facilitated communication among providers, facility staff, patients, and families to enhance patient care throughout episodes.
- Coordinated resource utilization and service continuity across healthcare continuum, optimizing patient transitions.
- Brentwood, TN
MDS Coordinator
Avante at Lynchburg
Lynchburg, USA
06.2016 - 05.2018
- Coordinated resident assessments ensuring compliance with federal and state regulations to enhance care quality.
- Managed interdisciplinary assessments for admissions, quarterly reviews, and annual evaluations, fostering collaboration among care teams.
- Developed individualized care plans based on patient needs and recovery goals.
- Collaborated with providers, therapists, nursing staff, residents, and families to ensure quality care delivery.
- Utilized electronic health records and assessment systems to monitor outcomes and identify opportunities for improvement.
- Reviewed documentation to ensure reimbursement accuracy and adherence to regulatory standards, supporting financial stability.
- Lynchburg, VA
Rehabilitation / Resource Pool Registered Nurse
Carilion Roanoke Memorial Hospital
Roanoke, USA
09.2015 - 06.2016
- Delivered comprehensive nursing care for medically complex rehabilitation and acute care patients to enhance recovery outcomes.
- Administered medications and therapies, closely monitoring treatment effectiveness to ensure optimal patient response.
- Coordinated multidisciplinary care plans to support patient recovery and discharge goals.
- Instructed patients and families on medications, disease processes, and treatment plans to empower them in managing health.
- Maintained accurate electronic documentation and monitored patient outcomes.
- Cared for patients with heart failure, pulmonary hypertension, pulmonary embolism, and end-stage renal disease.
- Roanoke, VA
Charge Nurse
Virginia Veterans Care Center
Salem, USA
01.2013 - 06.2015
- Supervised nursing care for residents with multiple chronic conditions including CHF, COPD, diabetes, CVA, asthma, and sepsis.
- Monitored treatment plans, communicating patient status changes to providers to ensure timely interventions.
- Fostered collaboration among nursing and interdisciplinary teams, improving coordination and continuity of care.
- Utilized SBAR communication and electronic health records, enhancing safety and effectiveness of patient care.
- Conducted chart audits to ensure documentation accuracy and regulatory compliance.
- Salem, VA
Triage / Back Office Nurse
Carilion Pediatric Associates Clinic
Roanoke, USA
10.2009 - 11.2012
- Executed patient triage, immunizations, screenings, and medication administration to ensure timely care delivery.
- Coordinated laboratory testing, prescription processing, and electronic medical record management to streamline patient services.
- Supported providers with clinical procedures and optimized patient flow for improved care efficiency.
- Educated patients and families regarding treatments, vaccines, and preventive care.
- Trained staff in electronic office systems and clinical processes.
- Roanoke, VA
Education
Associate of Science - Nursing
Breckinridge School of Nursing
Salem, VAPractical Nursing Diploma -
Bedford Memorial Hospital School of Nursing
Bedford, VASkills
- Care Coordination & Care Management
- Transitions of Care
- Clinical Assessment
- Discharge Planning
- Care Plan Development
- Chronic Disease Management
- Utilization Review
- Population Health Management
- Medicare & Managed Care
- Interdisciplinary Collaboration
- Clinical Documentation Review
- Regulatory Compliance
- Quality Improvement
- Electronic Medical Records (EMR/EHR)
- Patient Advocacy
- Patient and Family Education
Certification
- Registered Nurse (RN), Virginia
- Certified Community Voice Lay Health Advisor
- Certified Faith Community Nurse
Community Service
- Medical Reserve Volunteer
- Women's Outreach Organization Member (16 years)
- Former Women's Outreach President (5 years)
- Mission Outreach and Community Service Activities in the US & International
Timeline
RN Care Coordinator
Optum Health
12.2021 - Current
SICC- On-site
NaviHealth, Inc.
06.2018 - 12.2021
MDS Coordinator
Avante at Lynchburg
06.2016 - 05.2018
Rehabilitation / Resource Pool Registered Nurse
Carilion Roanoke Memorial Hospital
09.2015 - 06.2016
Charge Nurse
Virginia Veterans Care Center
01.2013 - 06.2015
Triage / Back Office Nurse
Carilion Pediatric Associates Clinic
10.2009 - 11.2012
Associate of Science - Nursing
Breckinridge School of Nursing
Practical Nursing Diploma -
Bedford Memorial Hospital School of Nursing