Melissa Elmore

Clinical Evaluation and Review

Currently am in the role of SME, which includes training new ECM's to educate and monitor their progression into their new role.

Create education tools for new ECM's to assist with their processes in addition to DTP's already in place for training.

Monitor the SME chat for inpatient requests, which includes training, problem solving and assisting other ECM's in completing cases correctly and in a timely manner to maintain timelines.

Review and evaluate cases for medical necessity against medical policy, benefits and/or care guidelines and regulations.

Complete work in accordance with timeliness, production, clinical quality/accuracy and compliance standards

Provide notifications to member and/or provider, according to regulatory requirements.

Assess appropriateness for secondary case review by the Medical Director (MD) for denials and coordinate as needed.

Coordinate peer-to-peer review upon provider request when members’ health conditions do not meet guidelines
Collaboration and Documentation

Communicate and collaborate effectively with internal and external clinical/non-clinical staff (including MDs) to coordinate work

Appropriately and fully document outcome of reviews and demonstrate the ability to interpret and analyze clinical information

Utilize detailed clinical knowledge to summarize clinical review against the criteria/guidelines to provide necessary information for MDs.

• Assess patient conditions, monitor behaviors and update supervising physicians with observations and concerns.
• Educate patients on skin care as a result of side effects from radiation therapy.
• Assist physicians with procedures including brachytherapy and SpaceOar.
• Monitor patients with pacemakers and defibrillators during treatment.
• Obtain vital signs, review medications, and medical history to prepare patient for office visit.
• Triage patient calls, medication refills, FMLA forms, prior authorizations, review lab results, and prep for radiation treatments/office visits.
• Peripheral/PAC access for IV contrast.
• Administer oral, IV and intra-muscular medications and monitor patient reactions.
• Utilize computerized Resource and Electronic Health Record (EHR) system.
• Stock clinical workstations and procedure rooms with necessary supplies.

• My first hire date for this company was 2001. I worked until the birth of my child in 2005, then returned in 2006.
• My job duties included peripheral IV access, PAC access, IV drug administration of therapeutic drugs, medication refills, prior authorizations, responsible for ordering specialty oral drugs, triage patient phone calls, electrocardiograms, injections, assists provider with bone marrows (including making the slides), FMLA and disability forms, chemotherapy education for patients, scheduling blood products, and rooming patients.

• Prepared and roomed patients before office visits, venipuncture, worked in the laboratory, assisted providers with procedures, medication refills, electrocardiograms, IV therapy, and immunizations.

• Assisted nurse with rooming patients, medication refills, IV therapy, electrocardiograms, injections, kept medical supplies in sufficient stock, assisted provider with various medical procedures, as well as administrative duties.