Melanie Sowards
Manassa,CO
Summary
Dedicated employee, looking forward to working with members navigating the process of obtaining prior authorizations, finding providers for their needs, and utilizing Out of Network exceptions, when necessary, for medical visits and procedures. Enjoy working with providers and contracting team throughout the process of obtaining Single Case Agreements in order to facilitate member care.
Overview
27
27
years of professional experience
Work History
Medical Business Clinician
Friday Health Plans
02.2022 - Current
- Evaluate prior authorizations for medical necessity and benefit coverage.
- Determine network status of providers.
- Communicate with members, requestors, and providers to better understand members' needs.
- Determine whether In-Network providers are appropriate for requested services.
- Send Single Case Agreement (SCA) requests to contracting team when Out of Network services are necessary and follow through to full execution of SCA.
- Established tracking system for processed authorizations.
- Coordinated team meeting to discuss authorizations and make determinations.
Registered Nurse, Labor and Delivery
San Luis Valley Health
04.2019 - 02.2022
- Provided care for patients in triage, labor, postpartum, and newborn nursery.
- Provided care for patients utilizing fetal and maternal monitoring equipment.
- Assisted provider during delivery, treatments, exams, and procedures.
- Monitored, recorded, and communicated patient condition as appropriate utilizing OBIX and Paragon.
- Provided patient and family education on labor, pain, and newborn care.
- Educated and assisted with breastfeeding.
- Received newborn babies at delivery, performed newborn assessments, and administered medications.
- Administered medications via oral, IV, and intramuscular injections and monitored responses.
Elementary School Teacher
North Conejos And Sanford School Districts
08.1996 - 12.2013
- Provided warm, supportive environment for developing academic, social, and emotional growth.
- Established open communication and positive relationships with students, parents, peers, and administrative staff.
- Designed and presented lesson plans in multiple academic subjects using variety of teaching techniques to appeal to various learning styles within assigned grade level.
- Created lesson plans to correlate with state curriculum standards and devised educational programs to meet educational objectives.
- Coached High School and Middle School Track
- Served on various committees
- Preceptor for student teachers
Education
Associate of Science - Nursing
Trinidad State Junior College
Alamosa, CO05.2019
Bachelor of Arts - Elementary Education
Adams State College
Alamosa, CO12.1995
Skills
- Team player
- Fast learner
- Strong communication skills
- Great time management
- Proficient use of Care Manager and HRP
- Utilize MCG and UpToDate to evaluate requests for medical necessity
Timeline
Medical Business Clinician
Friday Health Plans
02.2022 - Current
Registered Nurse, Labor and Delivery
San Luis Valley Health
04.2019 - 02.2022
Elementary School Teacher
North Conejos And Sanford School Districts
08.1996 - 12.2013
Associate of Science - Nursing
Trinidad State Junior College
Bachelor of Arts - Elementary Education
Adams State College