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Melinda Hancock, MSN, RN
Registered Nurse
Howard,PA
Work Preference
Summary
Registered nurse focused on medical review and compliance verification. Proficient in evaluating medical records to guarantee accuracy in claims processing and compliance with industry regulations.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Medical Review Nurse
CoventBridge
Remote
08.2024 - Current
- Conducted medical record reviews to ensure accurate claims payment and regulatory compliance.
- Assessed medical information for service appropriateness and medical necessity of claims.
- Identified discrepancies between submitted claims and supporting documentation.
- Participated in cross-functional meetings to provide updates and discuss findings.
- Analyzed data from clinical guidelines and government regulations to inform decision-making.
- Maintained current knowledge of healthcare regulations to ensure compliance with standards.
- Developed training materials on medical review processes for staff education.
- Assisted in training new employees on medical review procedures and best practices.
Medical Review Specialist III (Medicare Part A)
Empower AI
Remote
07.2023 - 07.2024
- Conducted comprehensive medical record and claim reviews for payment determinations based on Medicare guidelines.
- Performed in-depth claim analysis utilizing ICD-10, CPT, and HCPCS coding principles.
- Reviewed electronic health information and recorded medical review decisions in an electronic database module.
- Verified policies using internet and intranet resources to ensure compliance with regulations.
Sexual Health Nurse/Clinical Case Manager
AIDS Resource Alliance
State College, USA
07.2022 - 03.2023
- Conducted comprehensive counseling sessions on sexually transmitted infections, educating individuals on prevention and risk reduction strategies.
- Provided dedicated case management services for over fifty individuals living with HIV/AIDS, offering support and resources for overall well-being.
- Facilitated access to essential healthcare services by coordinating medical appointments and specialized treatments for timely care.
- Maintained accurate, confidential records in the in-house documentation system.
Utilization Review
Fidelis Care New York
Getzville, USA
02.2019 - 02.2020
- Utilized expertise in healthcare policies and guidelines to make informed decisions and recommendations regarding treatment plans and service utilization
- Facilitated access to high-quality, medically necessary healthcare for members, while adhering to contractual agreements to promote cost-effective utilization of resources
- Collaborated with the internal medical director to address cases that did not meet established criteria, submitting them for review and working toward resolution and approval
Clinical Quality Assurance Review
Independent Health
Buffalo, USA
04.2018 - 02.2019
- Collaborated with healthcare providers to develop and implement corrective action plans, improving compliance with quality standards.
- Analyzed patterns in member complaints, informing strategies that improved service and care delivery processes.
- Conducted thorough chart reviews to investigate member complaints regarding service and care quality, enhancing resolution processes.
- Documented findings, measures, and outcomes of investigations, ensuring accurate and comprehensive records for future reference and reporting purposes
Clinical Claim Review
UnitedHealth Group
Remote
04.2015 - 04.2018
- Conducted thorough claim reviews utilizing medical record review, nursing knowledge, and medical and reimbursement policies
- Ensured coding and billing accuracy through application of published guidelines and industry standards, supporting regulatory compliance
- Collaborated closely with internal medical directors, leveraging their expertise to address complex cases and ensure appropriate reimbursement
- Identified discrepancies or inconsistencies in claims documentation using analytical skills, resolving issues to uphold claim integrity
- Applied clinical knowledge and judgment to validate the appropriateness of services rendered, ensuring alignment with established medical guidelines and policies
- Maintained accurate, detailed documentation of claim reviews and findings in electronic systems, facilitating effective tracking and resolution
Education
Master of Science - Nurse Midwifery
Frontier Nursing University
Versailles, KY01-2022
Bachelor of Science - Nursing
Niagara University
Niagara University, NY01-2012
Associate of Science - Nursing
Niagara County Community College
Sanborn, NY05-2009
Skills
- Clinical claim review and documentation
- Healthcare regulations and compliance
- Policy navigation and verification
- Medicare compliance and utilization management
- Quality assurance and claim analysis
- ICD-10, CPT, and HCPCS coding
- AAPC certified coder training
- Training development and facilitation
- Office and Google tools proficiency
Certification
- Pennsylvania, RN730305
- New York, 620419
Timeline
Medical Review Nurse
CoventBridge
08.2024 - Current
Medical Review Specialist III (Medicare Part A)
Empower AI
07.2023 - 07.2024
Sexual Health Nurse/Clinical Case Manager
AIDS Resource Alliance
07.2022 - 03.2023
Utilization Review
Fidelis Care New York
02.2019 - 02.2020
Clinical Quality Assurance Review
Independent Health
04.2018 - 02.2019
Clinical Claim Review
UnitedHealth Group
04.2015 - 04.2018
Master of Science - Nurse Midwifery
Frontier Nursing University
Bachelor of Science - Nursing
Niagara University
Associate of Science - Nursing
Niagara County Community College