Melissa McGough
Urbana,IL
Summary
Knowledgeable Senior Claim Specialist with proven track record of leading organizations to growth and success through strategic planning and innovative problem-solving. Successfully managed diverse teams, driving operational efficiency, and fostering collaborative environments. Demonstrated excellence in financial oversight and stakeholder engagement.
Overview
33
33
years of professional experience
1
1
Certification
Work History
Executive Director
Carle Risk Management Company
10.2010 - Current
- Company Overview: Carle Health Inc.
- Oversight of Risk Management activities related to professional, general and property liability, incident reports, clinical risk management, claims administration, patient relations, workman’s compensation, professional peer review and diversion program.
- Report directly to General Counsel of a large healthcare system which encompasses eight hospitals, multi-practitioner group practice clinics and small business units throughout central Illinois.
- Conducts early resolution of potentially compensable events in compliance with settlement authority.
- Oversees claims administration of HPL and GL lawsuits, and acquire and collaborate with external defense counsel for the life of a claim.
- Responsible for implementing and oversight of risk assessments across all service lines in the healthcare institution.
- Work collaboratively with personnel and leadership to develop and implement education throughout the institution on risk identification and mitigation in support of a high reliability organization.
- Advise executive leadership of potential risk exposures and propose mechanisms to eliminate and mitigate these risks.
- Develop and maintain systems within the organization to detect, monitor, prevent, organize, measure, investigate, report and manage patient adverse events, incident reports and other indicators of potential patient harm and compensable events.
- Implement and manage a clearly defined 24/7 risk management program to support clinical operations.
- In collaboration with operational and clinical leaders, responds to sentinel events and other serious safety events, and provides expert advice in the management, disclosure and reporting of such events to administrative and clinical leadership and staff.
- Provide direct oversight of professional practice and peer review activities and collaborate with Medical Staff Office and Chief Quality Officer in compliance with medical staff bylaws and regulatory reporting requirements.
- Oversight of complaint and grievance resolution program in accordance Conditions of Participation for CMS and DNV NIAHO standards.
- Leads the organization-wide software system for safety event reporting, claims administration, complaints and grievances, peer review and root cause analysis. Including, training and monitoring of proper use, monitoring events for immediate and longer-term action, and trending and reporting of results that impact health system safety programs and initiatives.
- Active participant in nursing professionalism, professional practice, quality oversight, diversion and claims committees.
Utilization and Inpatient Care Management Manager
Health Alliance Medical Plans
03.1996 - 10.2010
- Manage a team of more than 70 clinical and non-clinical personnel performing high volume of utilization and inpatient management functions including prior authorization of inpatient and outpatient procedures, referral and ancillary service management, concurrent inpatient and discharge planning review, appeals and oversight of regulatory compliance for fully insured, Medicare Advantage, PPO and third-party administrative products. Clinical project manager over the electronic medical record and content management systems for the Medical Management Department including oversight of maintenance, upgrades and implementation of new information technology reducing manual processes by 50%. Participate as a clinical liaison for various departments including marketing, contracting, coding and claims which included participation in selecting and implementation of code review and claims products. Work concurrently with large Medical Director staff on policy and procedure development. Participate on Product Advisory Board with McKesson Health Solutions as a clinical representative for CCMS, InterQual, Clear coverage and CCU software.
Staff Registered Nurse
Carle Foundation Hospital
06.1995 - 03.1996
- General nursing duties within an oncology/hematology inpatient setting administering IVs, chemotherapy and pain management.
Staff Registered Nurse
Good Samaritan Regional Medical Center
06.1995 - 07.1992
- General nursing duties within an oncology/hematology and bone marrow transplant setting administering IVs, chemotherapy and pain management.
Staff Registered Nurse
Carle Foundation Hospital
07.1992 - 05.1991
- General nursing duties within an oncology/hematology inpatient setting administering IVs, chemotherapy and pain management.
Education
Master’s - Health Science Administration
University of Saint Francis
Joliet, IL01.2022
Bachelor’s - Science in Nursing
University of Saint Francis
Joliet, IL01.2013
Associate Degree - Nursing
Parkland College
Champaign, IL01.1991
Skills
- Program management
- Strategic planning
- Transformative leadership
- Operations oversight
- Analytical and critical thinker
- Innovation and creativity
- Relationship building
Certification
- Current Nursing license in good standing with the State of Illinois.
- Certified Professional in Health Care Risk Management 2014. Active member of ASHRM and ISHRM.
Awards
Member of the Professional Advisory Board for McKesson Health Solutions clinical software development from 2000 through 2010., Completion of Advanced Leadership Development certificate, in collaboration with Carle Health and University of Illinois Gies College of Business in December 2018., Guest Speaker for Central Illinois Medical-Surgical Nursing conference 2020-2024 on legal aspects of nursing, documentation and communication., Guest Speaker University of Illinois College of Applied Health Sciences for Health Administration, College of Nursing and School of Social Work program 2015-Present.
Timeline
Executive Director
Carle Risk Management Company
10.2010 - Current
Utilization and Inpatient Care Management Manager
Health Alliance Medical Plans
03.1996 - 10.2010
Staff Registered Nurse
Carle Foundation Hospital
06.1995 - 03.1996
Staff Registered Nurse
Good Samaritan Regional Medical Center
06.1995 - 07.1992
Staff Registered Nurse
Carle Foundation Hospital
07.1992 - 05.1991
Bachelor’s - Science in Nursing
University of Saint Francis
Associate Degree - Nursing
Parkland College
Master’s - Health Science Administration
University of Saint Francis
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