Melissa Gerry, BSN RN

• Critically analyze clinical documentation, evaluate treatment plan and apply appropriate evidence based medical criteria for requested health care services for 10-20 requests per day.
• Ensure accurate, concise documentation of supporting evidence found in the medical records and medical guidelines.
• Deliver timely clinical review decisions to approve prospective, concurrent acute and post acute authorization requests according to medical necessity guidelines using MCG, TRICARE, Medicare, or other standard of care resources when indicated.
• Refer authorization requests that do not meet the medical guidelines per approved criteria resources to the Medical Director with clear, concise summary of facts.
• Draft denial notice language per Medical Director non-coverage rationale and complete decision communication.
• Appeal and reconsideration coordination and response for acute and post acute concurrent denial and last covered day decisions.
• Develop relationships with facility staff and providers while collaborating on safe transition of care planning for members, educating on medical necessity guidelines, and identification of missing and necessary supporting clinical documentation.
• Facilitate discharge planning processes through early identification of needs, barriers to safe transition, evaluation of established discharge plan, and timely completion of utilization reviews.
• Contribute to positive team environment by being approachable, offering to assist with other work queues and offering subject matter expertise to peers and leaders.
• Identify opportunities and offer suggested solutions to standardize clinical review process and integrate non-clinical support for specific tasks to improve quality and efficiency for the clinical review.

• Collaborated with interdisciplinary teams to optimize patient outcomes through comprehensive care management strategies both during travel to injured worker medical appointments and telephonically.
• Identify and communicate Occupational Disability Guidelines (ODG) individualized to medical condition and adjusted for co-morbidities to the employer, claims adjusters, and medical providers.
• Analyze injured worker's job duties, job skills, employer needs and negotiate duties to accommodate the ordered work restrictions and facilitate safe and timely return to work.
• Educate injured worker and other key parties on medical conditions, treatments, medications, to promote adherence to the treatment plan and safety.
• Develop care plan with long and short term goals using SMART goals.
• Facilitate clarification of diagnosis with the treating provider as it relates to the injuries and mechanism of injury.
• Achieve cost savings as a result of case management activities.
• Produced eight or more billable hours per day per productivity goals.
• Communicate to claims adjuster through accurate comprehensive written case reports and invoice per customer guidelines.

• Apply motivational interviewing and therapeutic communication techniques to obtain key clinical information from telephonic triage to determine urgency level, recommend appropriate disposition, schedule appointments, teach appropriate home advice for 20-30 calls per day.
• Demonstrate consistent, clear, accurate written and oral communication
• Counseled patients via telephone according to established guidelines and protocols, advising on provider-established plans of care.
• Performed additional clinic and non-triage nurse duties such as instructing patients in prenatal education, blood pressure, diabetic/insulin teaching, respond to in office emergencies, track patients on long term anticoagulation per protocol, administering injections.

• Administered vaccinations accurately and safely, per standard orders, protocols, and telephonic provider support.
• Educated client about potential exposure to infectious disease based on travel plans and preventative measures to minimize risk of exposure.

Classroom, Lab, and clinical instructor with adult education program. 100% student pass rate for their Maine State CNA Assessment Test.

• Educated members on preventative health measures, promoting positive lifestyle choices and self-management techniques, addressing barriers to care with resource identification and coaching.
• Mentored new case management staff, fostering a supportive and educational atmosphere for growth and development.
• Established relationships with key program partners such as reinsurance, oncology and transplant center coordinators.
• Served as nurse case management subject matter expert resource for team members and for interdepartmental collaborative initiatives.
• Analysis of high dollar medical and pharmacy claims to identify potential cost savings strategies with executive leadership team.
• Performed long term coverage for manager's leave of absence, responsible for interviewing, hiring, training, daily supervisor support, leading team meetings.
• Co-speaker, Case Management Society of America, National Conference, June 2015

• Managed complex needs, chronic disease management, transition of care to identified high risk members per established case management standards using case management process, responsible for case load of 80.
• Teach/coach members to facilitate reaching established care goals.
• Increased member satisfaction by providing exceptional service, empathy, and timely assistance in resolving issues.
• Collaborate in development of department case management process, policy and procedures, customized assessments, standard program tools and educational resources.
• Apply critical thinking in accessing benchmark and proprietary medical necessity standards to perform utilization review, facilitate independent medical review attention to detail.
• Negotiate single case agreements, propose alternative treatment plans, extra-contractual agreements to produce hard and soft savings, review claims, review benefits for multiple clients of the Third Party Administrator (TPA) health plan.

• Apply InterQual medical necessity review criteria, Center for Medicare and Medicaid Services benefit and policy knowledge in timely maner, facilitating communication with patient's medical insurance to secure authorization for hospital days. Refer patient's lacking medical insurance to social work to identify and support coverage options for hospital and post hospital care needs.
• Assess patient social determinants of health. Collaborate with provider team to develop safe discharge plan, and coordinate services to facilitate timely transitions from the hospital to appropriate level of care.
• Develop responsibilities of new access case manager role
• Notable Achievements: Certified Case Manager in 2009

• Clinical coordination of nursing care to patients on 40 bed medical/surgical unit by managing staffing levels, supervising daily bed management, hands on patient care and clinical expert resource to promote consistent, high quality patient care and outcomes.
• Supervisor responsibilities include coaching RN, Nursing Assistant, and administrative staff, annual performance staff reviews, tracking required competencies and schedule management for approximately 70 staff.
• Teaching and updating the pre-operative patient course for elective joint replacement, American Heart Association BLS Instructor, PICC insertion certification, Emergency Nurse Association Trauma Nurse Certification, EMR trainer and content contributor.

• Advanced patient assessment, documentation, prioritization, time management, critical thinking, team work skills, while providing patient care to wide range of adults requiring high acuity hospital nursing care.
• Developed leadership, supervisory, and clinical expertise.