Melissa Hetzel
Griffith,IN
Summary
Dedicated and compassionate Registered Nurse (RN) with progressive career history in direct patient care, triage and care coordination in fast-paced environment. Proven to remain calm under pressure and skillfully handle difficult patients and high-stress situations. Consistently developing strong relationships with patients and families through empathetic communication, respectful attitude and excellent customer service.
Overview
25
25
years of professional experience
Work History
Senior Clinical Delegation Coordinator
BlueCross Blue Shield / Medix
11.2016 - Current
- Entered data, generated reports, and produced tracking documents.
- Improved team productivity with regular communication and progress updates, fostering collaborative work environment.
- Enhanced customer satisfaction by responding promptly to inquiries and addressing concerns professionally.
- Coached employees through day-to-day work and complex problems.
- Tracked records, filed documents and maintained communication between clients to manage office activities.
- Assisted in training and mentorship of new nursing staff members, contributing to positive work environment and high-quality patient care.
- Collaborated with physicians and other healthcare providers to ensure appropriate resource utilization for complex cases.
- Recognized as expert resource on organizational policies related to case management practice, regularly consulted by colleagues seeking guidance.
- Assisted in development and implementation of departmental policies and procedures related to case management, ensuring alignment with organizational goals and regulatory requirements.
- Conducted regular audits of clinical records to identify areas for improvement in documentation accuracy and compliance with regulatory standards.
- Audited charts and reviewed clinical documents to verify accuracy.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Appeals Nurse Reviewer
Advent Health Partners / Medix
09.2016 - 11.2016
- Maintained strict adherence to HIPAA regulations while handling sensitive patient information during course of case evaluations.
- Ensured compliance with regulatory requirements through meticulous documentation of cases, findings, and recommendations.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
Appeals Nurse Reviewer
Family Health Network /Community Care Alliance of Illinois
11.2015 - 09.2016
- Collaborated with interdisciplinary teams to develop strategies aimed at improving overall health outcomes for patient populations with high rates of chronic conditions.
- Improved patient outcomes by conducting thorough case reviews and offering clinical recommendations.
- Maintained strict adherence to HIPAA regulations while handling sensitive patient information during course of case evaluations.
- Expedited claims resolution process through comprehensive analysis of medical records and determination of medical necessity for services rendered.
- Upheld professional nursing standards by participating in continuing education opportunities, maintaining licensure requirements, and adhering to organization''s code of ethics.
- Optimized care coordination efforts by proactively addressing potential barriers to care delivery identified during case reviews.
- Facilitated accurate decision-making in complex cases by consulting with medical specialists when needed.
- Promoted collaborative work environment by fostering strong relationships with colleagues, support staff, and healthcare providers to ensure optimal patient care.
- Ensured compliance with regulatory requirements through meticulous documentation of cases, findings, and recommendations.
Chronic Care Management Coordinator
Alegis Care/Cigna
05.2013 - 11.2015
- Educated and evaluated clinical and support staff regarding care quality management regulations and standards of care.
- Coordinated referrals to specialists, hospitalizations, ER visits, ancillary testing, and other enabling services for patients.
- Collected and aggregated data to identify problems or trends, such as turnaround time and issues with physician offices.
- Contributed to development of department policies, procedures, and guidelines in line with best practices for care management coordination.
- Maintained accurate documentation of patient information, assessments, interventions, and progress in electronic medical records.
- Facilitated smooth transitions between levels of care by coordinating discharge planning activities with patients, families, and healthcare teams.
- Advocated for patients'' needs to ensure they received appropriate services while navigating complex healthcare systems effectively.
- Empowered patients to take charge of their health by providing education on self-management strategies and preventative measures.
- Addressed potential barriers to successful treatment outcomes proactively by identifying challenges early on in planning process.
- Supported family members in understanding and managing their loved one''s health conditions through education and guidance.
- Evaluated effectiveness of implemented care plans regularly, making adjustments as needed based on changing circumstances or patient feedback.
- Assessed patients'' needs and connected them to appropriate community resources for ongoing support.
- Managed diverse caseload of patients with various health conditions, requiring adaptability and excellent time management skills.
- Collaborated with healthcare providers to establish achievable goals for each patient''s care plan, promoting adherence and positive outcomes.
- Streamlined referral process, ensuring timely access to necessary specialists and services.
- Ensured continuity of care during staff transitions by maintaining clear communication channels among team members.
- Provided culturally competent care by considering individual preferences, beliefs, and values when developing care plans.
- Utilized evidence-based practices to guide decision-making in development of personalized care strategies for patients.
- Worked with insurance carriers to obtain authorization approvals for medications, supplies and equipment.
- Communicated with patients and family members to assist with information, provide literature and direct to community resources.
- Liaised with relevant clinical groups to develop linkages between areas.
- Liaised with other healthcare professionals to develop comprehensive patient care plans and provide highest quality of care.
- Communicated with patients, ensuring that medical information was kept private.
- Ordered all pharmacy supplies and kept check on inventory levels.
- Implemented successful healthcare program through professionalism, quality of care, medical teaching and patient satisfaction.
- Discussed medical histories with patients in effort to provide most effective medical advice.
- Spearheaded and implemented new projects to expand scope of engagement.
Care Management Specialist/Decision Maker – Long Term Care Claims Division
Bankers Life and Casualty Insurance, Inc.
10.2011 - 05.2013
- Followed all company policies and procedures to deliver quality work.
- Listened and responded to customer requests and forwarded necessary information to superiors.
- Interpreted clients' needs and introduced services to fit specific requirements.
- Created and managed project plans, timelines and budgets.
RN Clinical Advisor – Humana Beginnings
Humana Health Plans, Inc.
05.2003 - 07.2011
- Obtained and maintained nursing licensure for 11 states as requested by job description and provided telephonic care to members in those 11 states.
- Enhanced patient satisfaction through effective communication, empathy, and timely response to their needs.
- Educated patients on disease management and self-care techniques, promoting lifestyle changes for improved health.
- Managed complex cases of critically ill patients, ensuring optimal treatment plans were executed effectively.
- Developed strong relationships with patients'' families, providing emotional support while addressing concerns or questions about care plans.
- Devised individualized care plans tailored to each patient''s unique situation, optimizing clinical outcomes.
- Participated in professional development opportunities regularly to stay current on best practices in field of nursing.
- Managed patient caseloads effectively, ensuring timely interventions and thorough follow-ups to mitigate potential complications.
- Provided emotional support to patients during challenging times, fostering a sense of trust and rapport that contributed to better overall wellbeing.
- Educated patients, families and caregivers on diagnosis and prognosis, treatment options, disease process, and management and lifestyle options.
- Evaluated healthcare needs, goals for treatment, and available resources of each patient and connected to optimal providers and care.
- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
Nurse Review Coordinator
Humana Health Plans, Inc.
09.1999 - 05.2003
- Enhanced patient care by implementing evidence-based nursing practices and protocols.
- Collaborated with interdisciplinary teams for optimized patient treatment plans and outcomes.
- Mentored new nursing staff members, fostering teamwork and improving unit efficiency.
- Increased quality of care by participating in ongoing professional development opportunities such as workshops, conferences, and online courses.
- Maintained up-to-date knowledge on emerging trends in nursing practice to enhance effectiveness in delivering quality care.
- Contributed to cost-saving initiatives by identifying areas for waste reduction without compromising patient care quality.
- Identified and assisted with opportunities for performance improvement activities on unit and with other service areas.
- Organized and managed care of patients undergoing various therapies and procedures that were denied as not covered for HMO, PPO, Medicare Advantage Insurance Plans.
- Organized and managed care patients undergoing various therapies and procedures that were denied as not covered for HMO, PPO, Medicare Advantage Insurance Plans.
- Ensured that all lines of business were following all federal, state laws and regulations and contractual agreements for insurance coverage.
- Advocated for patients by communicating care preferences to practitioners, verifying interventions met treatment goals and identifying insurance coverage limitations.
- Audited charts and reviewed clinical documents to verify accuracy.
- Followed all personal and health data procedures to effectively comply with HIPAA laws and prevent information breaches.
- Facilitated therapeutic communication, conflict resolution and crisis intervention by redirecting negative behaviors and helping patients regain or improve coping abilities.
- Collaborated with large ASO groups for contractual coverage issues when services had been denied and obtained additional information to review those cases for possible coverage.
Education
Associate of Science - Nursing
Purdue University Calumet
Hammond, IN05.1994
Accounting/Business Major - Accounting
Indiana University Northwest
Gary, IN1989
Skills
- Customer Service
- Relationship Building
- MS Office
- Discretion and Confidentiality
- Document Management
- Presenting Ideas and Plans
- Regulatory Compliance
- Insurance Verification
- Microsoft Office
- Staff Training
- Policy and procedure modification
Timeline
Senior Clinical Delegation Coordinator
BlueCross Blue Shield / Medix
11.2016 - Current
Appeals Nurse Reviewer
Advent Health Partners / Medix
09.2016 - 11.2016
Appeals Nurse Reviewer
Family Health Network /Community Care Alliance of Illinois
11.2015 - 09.2016
Chronic Care Management Coordinator
Alegis Care/Cigna
05.2013 - 11.2015
Care Management Specialist/Decision Maker – Long Term Care Claims Division
Bankers Life and Casualty Insurance, Inc.
10.2011 - 05.2013
RN Clinical Advisor – Humana Beginnings
Humana Health Plans, Inc.
05.2003 - 07.2011
Nurse Review Coordinator
Humana Health Plans, Inc.
09.1999 - 05.2003
Associate of Science - Nursing
Purdue University Calumet
Accounting/Business Major - Accounting
Indiana University Northwest
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