Melissa Vanderbeck
Summary
Obtain a position with a leading organization that values innovative growth and solutions that provide the opportunities to utilize the knowledge and skills gained from a diversified nursing background.
Perceptive Manager with experience in improving and directing operations through effective motivational strategies and strong policy enforcement which encourages employees to work at peak performance levels. Proficient in best practices, market trends and regulatory requirements of industry operations. Talented leader with analytical approach to business planning and day-to-day problem solving. Experienced leader in expanding global strategic operations. Current experience in the health care insurance industry.
Overview
31
31
years of professional experience
Work History
Manager, Clinical Claim Review
United Health Group-Optum
05.2017 - Current
- Expanded cross-functional organizational capacity by collaborating across departments on priorities, functions, and common goals
- Performed statistical analysis to gather data for operational and forecast team needs
- Recruited and hired top performers to add talent and value to department
- Collaborating with global partners to build out training and quality processes
- Hire top performers for a cross functional global organization
- Accomplish multiple tasks within established timeframes
- Reduced process bottlenecks by training and coaching employees on practices, procedures, and performance strategies
- Onboarding new employees with training and new hire documentation
- Maintained detailed records of daily progress to identify and correct areas needing improvement
- Resolved staff member conflicts, actively listening to concerns, and finding appropriate middle ground
- Creating an inclusive environment where staff feel part of a team and valued with employees that work entirely remote.
Medical/Clinical Claim Review RN and Case Manager
United Health Group-United HealthCare/Optum
05.2012 - 01.2017
- Medical Claim review for post service claims adjudication utilizing company policies and procedures as well as contract requirements
- Monitor provider billing for fraud waste and abuse
- Manage health care costs by referencing company policies and procedures, best practice in medical treatment plans, and clinical practice
- Provided outreach for additional information for medical claim reviews for initial and re-review as well as medical necessity.
Inpatient Care Management RN
United Health Group-United HealthCare/Optum
05.2002 - 01.2012
- Provided patient education and support with challenging medical diagnosis
- Managed bed day admissions and medical costs by reviewing medical appropriateness for inpatient admissions
- Managed discharge planning and appropriate discharge planning secondary level of care
- Managed admissions and criteria for extended stay for Skilled Nursing Facility level of care
- Provided outreach for additional information for medically necessary concurrent review.
Registered Nurse
St Charles County Pediatrics
01.2001 - 01.2002
- Supported an office with six physicians and three nurse practitioners with Triage services and Back Office duties
- Recognition for excellence in duties and designated to train new employees after being with the office after only two weeks.
Registered Nurse Care Counselor
Express Scripts, Inc.
01.1998 - 01.2001
- Supported a 24/7 Triage Health Management call center for pediatric and adult clients
- Administered recruitment and education services for the Disease Management program
- Provided customer service and support for Pharmacy Benefit clientele
- Facilitated support for Hepatitis program, Breast Cancer Awareness program, RSV Synagis program and Infertility Injectables program
- Implemented Prescription Compliance and Drug Choice Management, with one-on-one client support while providing quality support with follow-up and satisfaction calls
- Awarded multiple bonuses for excellence in job performance, attendance, and meeting and exceeding personal and team standards
- Promoted to lead care counselor in a minimal amount of time
- Serviced a case management load of 150 clients
- Handpicked by management to serve Drug Choice Management clientele and Prescription Compliance initiative
- Handpicked by management to service on quality assurance and audit teams.
Registered Nurse
ESSE Health
01.1996 - 01.1998
- Provided physician support in both front and back office duties
- Designed and implemented a protocol for Port A Cath usage, in office
- Assisted with the set up, training, and implementation of new computer office system
- Interfaced with over 65 patients daily
- Provided support for entire office during staffing shortage
- Processed Claims, coding, billing, worked with Medicare and commercial both electronic and paper claims
- Worked with denials.
Registered Nurse
Deaconess Health Systems
01.1993 - 01.1996
- Provided client services for the Oncology unit with Medical/Surgical and Obstetrics/Gynecology overflow clients
- Certified in Chemotherapy administration
- Supervised Licensed Practical Nurses, Patient Care Technicians, and Student Nurses
- Served as Charge Nurse of the Unit
- Acknowledged by manager for supportive care for clients and families
- Acknowledged by manager and clinical specialists for proficiency in insertion of intravenous catheter sites.
Education
B. S. Nursing -
Deaconess College of Nursing
St. Louis, MOGreen Belt Six Sigma Certification -
Skills
- Quality Assurance Policies
- Prioritizing and Planning
- Staff Recruitment and Hiring
- Problem Anticipation and Resolution
- Scout for Just Right Service (JRS) Six Sigma Based
- Medical Records Review
- Proficient in Microsoft programs
Timeline
Manager, Clinical Claim Review
United Health Group-Optum
05.2017 - Current
Medical/Clinical Claim Review RN and Case Manager
United Health Group-United HealthCare/Optum
05.2012 - 01.2017
Inpatient Care Management RN
United Health Group-United HealthCare/Optum
05.2002 - 01.2012
Registered Nurse
St Charles County Pediatrics
01.2001 - 01.2002
Registered Nurse Care Counselor
Express Scripts, Inc.
01.1998 - 01.2001
Registered Nurse
ESSE Health
01.1996 - 01.1998
Registered Nurse
Deaconess Health Systems
01.1993 - 01.1996
B. S. Nursing -
Deaconess College of Nursing
Green Belt Six Sigma Certification -
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