Melissa Warren

• Develop comprehensive audit plans in adherence to predefined objectives and standards.
• Ensure regulatory compliance through monthly auditing of clinical operations in Utilization Management (UM) and Case Management (CM), covering all lines of business.
• Assess clinical staff regarding appropriate decision-making and policy adherence.
• Perform confidential Alertline reviews for reported ethics concerns.
• Successfully communicates identified issues to QA managers, fostering a collaborative approach towards resolution.

• Maintained close oversight of provider and member appeal submissions/resolutions to ensure adherence to internal and regulatory requirements.
• Conducted monthly audits of appeals to ensure compliance with quality standards.
• Monitored KPIs to evaluate performance and identify areas for improvement.
• Created monthly reports for senior management summarizing operational performance metrics.
• Led a team of 10 employees, ensuring high productivity and quality performance.
• Coached, mentored and trained team members in order to improve their job performance.
• Supervising a team of 2 in the Claims Workflow department, successfully ensuring that claims issues concerning UM authorizations were resolved promptly.

• Evaluated inpatient services for members to achieve optimal outcomes, cost efficiency, and adherence to state and federal regulations.
• Conducted inpatient authorization reviews and analyzed clinical service requests from providers in accordance with evidence based clinical guidelines (MCG).
• Ensured compliance with organizational policies and procedures related to utilization management processes.
• Collaborated with medical directors and care management team.

Ciox Health: Appeals Review/ HEDIS Nurse

• Evaluated clinical cases and abstracted essential clinical information to meet the criteria for inpatient hospital admissions.
• Achieved an 84% success rate in the overturn of denied hospital stays through the writing of clinically supported, professional appeal letters.
• Played a key role as a member of the HEDIS team, extracting and analyzing measurement data for various providers.

Brookdale Senior LIving: Healthcare Administrator

• Directed a highly skilled team of 70, responsible for providing care to 80 residents in an assisted living and dementia care facility.
• Drove initiatives resulting in enhanced quality outcomes, customer satisfaction and adherence to budgeting standards.
• Played a pivotal role in the development of new staff members by delivering comprehensive training programs, offering ongoing coaching and mentoring support, as well as overseeing disciplinary procedures when necessary.

Trilogy Health Services: Regional Corporate Assessment Nurse

• Supported compliance with CMS and State regulations by overseeing the accurate completion of the RAI Process at 10 skilled nursing campuses.
• Conducted case audits and chart reviews to ensure accurate information captured to support Medicare/Medicaid billing rates.
• Educated physicians, therapists, and nurses on the importance of proper documentation for medical coding and billing.
• Completed clinical assessments to determine medical billing rates for Medicare and Managed Care patients.
• Evaluated CMS STARS outcomes and identified key areas for improvement based on assessments submitted.

• Reviewed inpatient and outpatient hospital stays, behavioral health, and dialysis claims to assess eligibility for coverage/payment according to State Medicaid Program's Federal Emergency Services guidelines.
• Performed meticulous clinical reviews on Outlier and Professional claims, resulting in prompt and accurate adjustments.
• Conducted prior authorization reviews for Tribal ALTCS members.
• Evaluated and documented non-coverage reasons in denial summaries.