Melissa Burns
North Attleboro,MA
Summary
Professional nurse with strong background in utilization management processes, ensuring efficient use of healthcare resources. Skilled in assessing patient care needs, coordinating treatment plans, and ensuring compliance with healthcare regulations. Known for effective collaboration with multidisciplinary teams and driving results in dynamic healthcare environments. Reliable and adaptive, with focus on quality outcomes and patient advocacy.
Overview
19
19
years of professional experience
Work History
Regional Utilization Management Nurse Manager
VitalCore Health Strategies
06.2024 - Current
- Supported cost containment efforts by identifying over utilization trends and recommending strategies for improvement.
- Applied critical thinking skills to assess complex medical cases and determine appropriate levels of care in accordance with industry benchmarks.
- Reduced hospital readmissions through effective discharge planning and coordination of post-discharge care.
- Performed prior authorization review of services requiring notification.
- Performed concurrent and retrospective reviews to determine medical necessity based upon InterQual criteria.
- Submitted cases for criteria failures and helped facilitate resolutions and approvals.
- Expedited claim resolution by effectively communicating clinical rationale for treatment recommendations to insurance reviewers.
- Increased efficiency in case management documentation by maintaining organized records and utilizing electronic medical record systems.
- Coordinated seamless transitions of care across multiple settings including acute care hospitals, rehabilitation facilities, and home care services.
- Maintained up-to-date knowledge of payer-specific guidelines to ensure accurate authorizations for medically necessary services.
- Facilitated communication between healthcare providers, patients, families, and insurance carriers to optimize outcomes.
- Participated in quality improvement initiatives to enhance the overall standard of care within the organization.
- Promoted a positive work environment by mentoring new staff and serving as a resource for clinical questions and concerns.
Utilization Review Nurse Manager
Wellpath
08.2020 - 07.2024
- Reduced healthcare costs through efficient utilization of resources and identification of unnecessary treatments or procedures.
- Ensured compliance with regulations and accreditation standards by maintaining accurate documentation of all utilization review activities.
- Ensured prospective, concurrent and retrospective reviews were performed using nationally recognized criteria and evidence based standards.
- Assisted with analyses of medical necessity, level of care, care progression, and resource utilization.
- Handled all management level responsibilities for UM staff, including performance reviews, employee development, hiring, coaching, counseling, and retention.
- Provided leadership guidance and acted as a resource to the Regional Care Manager.
- Oversaw UM process improvements as needed to ensure quality and service excellence.
- Utilized data research to develop and implement programs to reduce length of inpatient stays and decrease admissions.
- Evaluatedand recommended policy improvement related to utilization review system, including appropriate resource utilization and identification of non-billable days.
- Provided statistical data as it applies to financial impact for offsite services.
- Established and monitored progress towards goals for UM program, including turnaround times, timeliness, and quality of reviews, training and physician outreach efforts.
- Investigated incident reports submitted by patient and client.
Registered Nurse, Cardiac Telemetry
Sturdy Memorial Hospital
05.2019 - 12.2021
- Improved patient outcomes by consistently monitoring cardiac telemetry and promptly responding to critical changes.
- Provided comprehensive cardiac education to patients and families, empowering them in self-care management post discharge.
- Ensured optimal clinical outcomes for cardiac patients through timely identification of potential complications and prompt intervention.
- Contributed to quality improvement initiatives by identifying areas for improvement and implementing evidence-based solutions.
- Optimized patient outcomes in high-stress scenarios by remaining calm, focused, and utilizing critical thinking skills to provide appropriate interventions.
- Skillfully operated various medical equipment such as IV pumps, monitors, and feeding tubes to optimize patient care delivery.
- Demonstrated expertise in various cardiac procedures such as EKG interpretation, defibrillation, cardioversion, and administration of emergency medications.
- Supported new nursing staff through mentorship, precepting, and serving as a resource in navigating complex cardiac cases.
- Reduced medication errors by diligently verifying all orders and maintaining accurate documentation.
- Provided emotional support to patients and families during difficult medical situations, fostering trust and rapport.
- Improved patient outcomes by providing high-quality nursing care and closely monitoring vital signs.
MDS Coordinator
Maples Rehabilitation and Medical Center
02.2016 - 08.2020
- Set schedules for staff to start and complete MDS assessments and care plan meetings.
- Ensured timely completion of all MDS assessments, maintaining full compliance with federal and state regulations.
- Maintained up-to-date knowledge on CMS guidelines and changes to ensure accuracy in reporting and reimbursement processes.
- Enhanced patient care quality by implementing comprehensive MDS assessments and care plans.
- Collaborated with nursing staff to provide accurate and timely clinical assessments for each resident, leading to improved overall care.
- Assessed electronic medical record for required documentation to support MDS coding.
- Verified prompt and accurate completion of MDS activities for billing.
- Collaborated closely with therapy departments to accurately capture rehabilitation needs within MDS documentation, supporting appropriate resource allocation for residents'' needs.
- Provided ongoing education for nursing staff regarding MDS best practices, contributing to a knowledgeable and skilled workforce.
- Monitored changing regulations related to RAI/MDS requirements, keeping staff informed about updates that impact their daily work routines.
- Implemented interdisciplinary meetings focused on individualized care plan development, resulting in more targeted interventions and improved resident outcomes.
- Completed minimum data set assessments with strong collaboration across business, provider and clinical disciplines.
- Developed a comprehensive system for tracking MDS completion deadlines, ensuring timely submissions and minimizing the risk of financial penalties.
- Established regular review processes to evaluate the accuracy and completeness of MDS records, leading to proactive identification of potential issues before they escalate.
- Developed strong relationships with interdisciplinary team members to facilitate efficient collaboration on resident care planning.
- Led weekly utilization review to go over recent clinical activities.
- Reduced errors in data collection by streamlining the MDS process and improving communication among interdisciplinary teams.
- Conducted audits of current MDS records to identify discrepancies and improve record accuracy, enhancing reimbursement rates for the facility.
- Provided guidance to nursing staff on accurate completion of Section GG assessments, enhancing overall documentation quality and supporting appropriate Medicare/Medicaid reimbursement rates.
- Complied with federal and state regulations for completion and coordination of RAI process.
- Trained staff in correct techniques for completing and signing MDS assessments.
- Supported facility-wide initiatives aimed at reducing hospital readmissions by closely monitoring MDS data for trends and potential areas of concern.
- Identified areas of improvement in the facility''s quality measures through thorough analysis of MDS data, resulting in targeted interventions and better outcomes for residents.
- Improved communication between departments by establishing clear protocols regarding assessment timelines, leading to more efficient care planning processes.
Education
Bachelor of Science - Nursing
University of Rhode Island
Kingston, RI08-2017
Associate of Science - Nursing
Massachusetts Bay Community College
Wellesley Hills, MA12-2010
Practical Nurse Licensure - Nursing
University of Massachusetts, Lowell
Lowell, MA05-2003
High School Diploma -
Attleboro High School
Attleboro06-1999
Skills
- HIPAA compliance
- InterQual criteria
- Utilization review
- Utilization management
- Medical necessity evaluation
- Care coordination
- Medicare/Medicaid
- Research and data collection
- Records analysis
- Healthcare regulations
- Electronic health records proficiency
- Quality improvement
Licenses
- Registered Nurse in the State of Massachusetts, License number RN2271370
- Registered Nurse in the State of Rhode Island, License number RN52499
- ACLS and BLS certified through the American Heart Association
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
swipe to browse
Work Preference
Work Type
Full TimePart TimeWork Location
RemoteHybridImportant To Me
Work-life balanceCompany CultureFlexible work hours4-day work week401k matchWork from home optionCareer advancementPaid time offTeam Building / Company RetreatsPersonal development programsQuote
Success is not final; failure is not fatal: It is the courage to continue that counts.
Winston S. Churchill
Timeline
Regional Utilization Management Nurse Manager
VitalCore Health Strategies
06.2024 - Current
Utilization Review Nurse Manager
Wellpath
08.2020 - 07.2024
Registered Nurse, Cardiac Telemetry
Sturdy Memorial Hospital
05.2019 - 12.2021
MDS Coordinator
Maples Rehabilitation and Medical Center
02.2016 - 08.2020
Bachelor of Science - Nursing
University of Rhode Island
Associate of Science - Nursing
Massachusetts Bay Community College
Practical Nurse Licensure - Nursing
University of Massachusetts, Lowell
High School Diploma -
Attleboro High School
Similar Profiles
Stanley PowellStanley Powell
Substance Abuse Counselor at VitalCore Health StrategiesSubstance Abuse Counselor at VitalCore Health Strategies
Aubrey CunninghamAubrey Cunningham
Emergency Medical Technician at VitalCore Health StrategiesEmergency Medical Technician at VitalCore Health Strategies
Kurt SmithKurt Smith
RN at VitalCore Health StrategiesRN at VitalCore Health Strategies
Mildred OliverMildred Oliver
LPN at VitalCore Health StrategiesLPN at VitalCore Health Strategies
Lynn SiroisLynn Sirois
Site Coordinator at Hockomock Area YMCASite Coordinator at Hockomock Area YMCA