Melissa Poole
Reno,Nevada
Summary
Dedicated Registered Nurse with over a decade of experience in Utilization Management, specializing in Prior Authorization with previous UM Supervisor experience. Seeking a role as Prior Authorization Supervisor with Hill Physicians Medical Group.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Prior Authorization Nurse
Hill Physicians Medical Group
01.2025 - Current
- Efficiently processed requests for pre-authorization of services including but not limited to diagnostic tests, outpatient surgery, durable medical equipment.
- Efficiently mastered several different specialty queues to fit team need.
- Quickly became a vital member of the prior authorization team
- Reviewed up to 110 authorizations in one day to ensure team met turnaround time
- Performed Pre Cert for inpatient procedures and admissions.
- Performed a minimum of 50 daily reviews.
- Receive stellar feedback from leadership.
- Quickly mastered Epic Tapestry.
- Participated in interdisciplinary team meetings, collaborating with other healthcare professionals to ensure seamless coordination of care for patients requiring prior authorizations.
- Dedicated to being a team player for the betterment of the department.
Prior Authorization Nurse
San Francisco Health Plan
06.2023 - 12.2024
- Conducted Medical Necessity Reviews For: DME, Outpatient Surgeries, Imaging, Gender Affirming Care, Chemotherapy, and any specialty available in medical care.
- Prioritized heavy workload based off of NCQA turnaround times.
- Criteria used for reviews included Milliman, NCCN, Medi-Cal, CMS and Internal Policies.
- Pre Cert Reviews for procedures needing inpatient admission.
- Prepared authorization requests to the Medical Director that were not approvable by RN.
- Drafted denial letters that were at 5th grade level or below.
- Collaborated with healthcare providers to ensure accurate submission of required documentation for timely authorizations.
UM Supervisor
Excel MSO
12.2022 - 05.2023
- Led a UM team of 20+ nurses including prior authorization, case management and concurrent review staff.
- Supervised and coordinated activities of staff to ensure compliance with established policies, procedures, and standards.
- Oversaw the training of new employees on job responsibilities and expectations as well as revamped training program to create more efficient ramp up period.
- Actively participated in monthly UMC meetings.
- Collaborated with Senior Medical Director to create internal policies based off DHCS APL's.
- Collaboratively led a team of 20+ nurses from Prior Authorization, Concurrent Review, and Case Management.
- Assumed role of Project Manager for all External Audits for 19 Health Plans.
- Performed Performance Improvement Plans as needed.
- Trained new Medical Director
- Fostered a positive team environment by recognizing individual and team accomplishments.
- Managed team schedules and delegated daily tasks to ensure efficiency.
- Effectively transitioned from co-worker to a leadership position with stellar feedback from both superiors and staff.
- Oversaw daily operations of the department, ensuring smooth workflow and timely completion of tasks.
- Participated in the hiring of new employees.
- Handled all PTO requests.
- Conducted monthly 1:1 meetings with individual staff
- Acted as interim manager.
Prior Authorization Nurse
Excel MSO
10.2019 - 12.2021
- Performed Daily Reviews for all LOB; Medi-Cal, Medicare, and Commercial.
- Used Contracting/Ancillary Grids to determine if providers/facilities were in-network or out of network for 19 Health plans.
- Reviewed Cases for Medical Necessity, Out of Network, and Benefit Eligibility which included: Pre Cert for inpatient admission, outpatient surgeries, Imaging, DME, Home Health, and all medical specialties.
- Expert use of CMS criteria, Medi-Cal Criteria, MCG, Apollo, NCCN, Prescribing Information.
- Credited with highest level of productivity while maintaining excellent quality audit scores.
- Promoted to UM Supervisor.
Grievance and Appeals Nurse
Aetna, a CVS Health Company
04.2018 - 05.2019
- Conducted investigations and reviews of member and provider medical necessity and OON appeals.
- Reviewed prospective, inpatient or retrospective medical records of denied services for medical necessity.
- Extracted and summarized medical information for the medical director, consultants and other external review.
- Prepared recommendations to either uphold or deny appeal, and forward to the medical director.
- Generated written correspondence to providers and member.
- Actively participated in Panel Hearings.
- Exceeded goals in both productivity and audit findings.
Concurrent Review RN
Anthem
10.2016 - 01.2018
- Reviewed Inpatient Admissions, Skilled Nursing, LTACH, Home Health, DME.
- Attended and participated in multidisciplinary team rounds to collaborate on complex cases.
- Extracted and Summarized case facts to prepare review for the medical director when cases did not meet medical necessity or were OON.
- Performed CCS reviews.
- Recruited for weekend nurse project by UM Manager.
Case Manager
Sante Health Systems
07.2014 - 06.2016
- Participated in team meetings to discuss case management strategies for individual cases.
- Educated clients on available community resources and how to access them effectively.
- Created individualized service plans in collaboration with clients, families, and other professionals.
- Performed inpatient and outpatient reviews for Assigned Employer Groups using Interqual and Milliman Guidelines.
- Led quarterly meetings with Employer Groups regarding member activity.
NICU/PICU RN
Valley Childrens Hospital
07.2013 - 04.2014
- Assessed and monitored neonate and pediatric patients health, including vital signs and medical histories.
- Developed individualized Care Plans according to need.
- Provided emotional support for parents during difficult times with child illness or loss.
- Administered all bedside care for assessments, medications, procedures.
Travel Telemetry RN
Nursing Partners Inc
10.2004 - 10.2005
- Traveled to various Bay Area Hospitals as a telemetry RN.
- Responded to emergency situations quickly and effectively.
- Administered IV drips, Opioids, IM injections, PO medications and blood products.
- All bedside care, monitoring heart rates and rhythms, patients with strokes, post cardiac catheterization, 1-2 day post CABG patients.
Cardiology RN
Valley Heart Associates
06.2003 - 10.2004
- Reviewed and managed patients care on coumadin therapy.
- Triaged patients for MD
- Extensive patient teaching regarding health, procedures and medication.
- Diagnostic testings including EKGs and participating with stress testings.
Float Pool RN
Doctors Hospital of Modesto
12.2001 - 10.2004
- Performed ongoing patient assessments, notifying supervising MD of abnormal findings.
- Worked on all specialty floors including but not limited to, Telemetry, Oncology, Med-Surg, Surgical, Short stay, Pediatrics PACU.
- Cared for tracheostomy care patients for both peds and adults.
- G-tube, chest tube, and central line care and removal.
- All medication and blood product administration.
Education
Associate in Science (A.S.) - Registered Nursing
San Joaquin Delta College
Stockton, California12.2001
Skills
- Training and mentoring
- Clinical documentation
- Milliman
- InterQual
- EPIC Tapestry
- NCCN
- MS word
- Excel
Certification
- Registered Nurse 595660 California
- Registered Nurse 857745 Nevada
Timeline
Prior Authorization Nurse
Hill Physicians Medical Group
01.2025 - Current
Prior Authorization Nurse
San Francisco Health Plan
06.2023 - 12.2024
UM Supervisor
Excel MSO
12.2022 - 05.2023
Prior Authorization Nurse
Excel MSO
10.2019 - 12.2021
Grievance and Appeals Nurse
Aetna, a CVS Health Company
04.2018 - 05.2019
Concurrent Review RN
Anthem
10.2016 - 01.2018
Case Manager
Sante Health Systems
07.2014 - 06.2016
NICU/PICU RN
Valley Childrens Hospital
07.2013 - 04.2014
Travel Telemetry RN
Nursing Partners Inc
10.2004 - 10.2005
Cardiology RN
Valley Heart Associates
06.2003 - 10.2004
Float Pool RN
Doctors Hospital of Modesto
12.2001 - 10.2004
Associate in Science (A.S.) - Registered Nursing
San Joaquin Delta College