Melissa Babcock
Rockport,TX
Summary
Dynamic healthcare professional specializing in utilization review of inpatient admissions, outpatient surgeries, and ancillary services, with a strong focus on assessing medical necessity and service appropriateness through established clinical review criteria. Expertise in documenting review determinations and effectively communicating with providers and members within set timeframes to ensure seamless case management. Proven ability to identify and escalate cases that do not meet clinical standards to the Medical Director while collaborating with physicians to enhance service delivery across the healthcare continuum. Recognized for leadership in team dynamics, conflict resolution, and strategic planning, consistently driving operational excellence and fostering a productive work environment.
Overview
28
28
years of professional experience
1
1
Certification
Work History
Supervisor, UM Prior Authorizations
Molina Healthcare Inc
Remote
12.2022 - 02.2026
- Managed a team of 10 care review clinicians, focusing on improving clinical review processes and outcomes.
- Manage schedules, payroll and provide support to upper management
- Managed scheduling and resource allocation to optimize workforce productivity across departments.
- Implemented process improvements resulting in increased operational efficiency and service quality.
- Led team training sessions to enhance staff performance and patient care delivery.
- Developed performance metrics to evaluate team effectiveness and drive continuous improvement initiatives.
- Developed staff skills through targeted training programs, resulting in improved performance and career growth opportunities.
- Supervised daily operations to ensure compliance with healthcare regulations and quality standards.
RN Care Advisor – Utilization Management
Evolent Health
Remote
01.2022 - 12.2022
- Performs utilization review of inpatient admissions, outpatient surgeries, and ancillary services.
- Concludes medical necessity and appropriateness of services using clinical review criteria.
- Document all review determinations and contacts providers and members according to established timeframes.
- Appropriately identifies and refers cases that do not meet established clinical criteria to the Medical Director.
- Partners with physicians and other providers to facilitate provision of services throughout the health care continuum.
- Uses Milliman, PEGA, QNXT and InterQual
Care Review Clinician - Prior Authorization Nurse
Molina Healthcare
Remote
12.2020 - 01.2022
- Assessed services for members to ensure optimum outcomes, cost effectiveness and compliance with all state and federal regulation and guidelines
- Analyzed and identified appropriate benefits and eligibility for requested treatments and or procedures
- Conducted prior authorization reviews for outpatient and inpatient procedures
- Collaborated with multidisciplinary teams to promote the Molina Care Model
- Used Interqual and Milliman
Clinic Team Lead
Health By Design
San Antonio, TX
05.2017 - 12.2020
- Coordinate and supervise the activities of clinical team members engaged in clinical care for patients under the supervision of a Physician or provider for the diagnosis, treatment and prevention of disease
- Organize and assign duties and tasks to clinical team members
- Establish clinical team member work schedules daily/weekly and request staff from Area Director as needed
- Monitor daily performance of clinical team members to ensure duties are completed accurately, efficiently and timely. Monitor and control overtime.
- Evaluate performance of clinical team members and conduct verbal and written performance evaluations after 30 days, 90 days and annually
- Ensure high-quality clinical care for patients by reviewing and researching concerns or complaints and recommending corrective action as appropriate
- Maintain adequate clinical supplies & ensure cost effectiveness
- Ensure clinical policies and procedures comply with current state and federal regulations
Nurse Educator and Staff Nurse
Health By Design, a Medici Company
San Antonio, TX
01.2011 - 04.2017
- Provided professional patient focused education and coaching to individuals that participated in our wellness health evaluations
- Performed telephonic coaching to participants regarding their lab results & Biometrics
- Regarding test results, medication refills and questions
- Assist with on-site flu immunization clinics at various locations
Nurse Manager & Assistant Administrator
Health By Design
Main Location
04.2008 - 04.2010
- Responsible for managing, supervising, and coordinating the operations of the Executive Exam center, On-site Clinics and Wellness Divisions
- Directly supervised 24 employees in various departments
- Responsible for interviewing, hiring, training, planning, assigning, and directing work of staff
- Conducted performance appraisals for staff annually
- Developed, implemented, and evaluated clinic policies, goals and objectives
- Trained and served as a “Superuser” during the transition to Electronic Medical Records
- Advanced knowledge of eClinicalWorks system
Staff Nurse
Health By Design
Main Location
08.2007 - 04.2008
- Perform executive exams that include lab work, hearing tests, vision tests, spirometry, cardiac stress tests via treadmills, DEXA and carotid ultrasounds
- Assisted in clinics as staffing needs required
Staff Nurse, PreOp/PACU/Procedure Room
Sonterra Endoscopy Center
San Antonio, TX
06.2005 - 12.2006
- Provided nursing care to patients during the preoperative, procedure and recovery portion of the procedure.
- Daily tasks included starting IV’s, reviewing medical history, administering IV conscious sedation and monitoring patients during the recovery phase
- Provided patient teaching daily pre and post-procedural.
- Assisted with Quality Assurance
Staff Nurse, Post Anesthesia Care Unit
Methodist Ambulatory Surgical Center
Stone Oak-San Antonio, TX
05.2004 - 06.2005
- Performed duties as a recovery room nurse caring for adult and pediatric patients for many types of post-surgical patients to include orthopedic, ENT, OB/GYN, cosmetic, ophthalmic, and general surgical
- Assist with conscious sedation for pain management procedures
- Served on the Quality Assurance/Quality Improvement Committee
Clinic Staff Nurse
PRMA of South Texas
San Antonio, TX
04.2003 - 05.2004
- Responsible for providing preoperative and post-surgical care to patients in an office setting
- Performed preoperative and postoperative teaching to patients regarding cosmetic and reconstructive surgeries.
- Assisted physicians with surgical procedures in the office setting.
- Skills included suture removal, Jackson Pratt drain assessment/removal, wound care & dressing changes
Staff Nurse, Recovery Room (PACU)
Northwest Florida Surgery Center
Panama City, FL
03.2001 - 04.2003
- Performed duties as a recovery room nurse caring for adult and pediatric patients
- Provided post-surgical care to patients recovering from orthopedic, ENT, OB/GYN, cosmetic, ophthalmic, GI and pain procedures
Staff Nurse, Intensive Care Unit
Williamsburg Community Hospital
Williamsburg, VA
07.2000 - 03.2001
- Provided care to general intensive care unit patients
Staff Nurse, Intensive Care Unit
Baptist Medical Center
San Antonio
01.1998 - 07.2000
- Provided care to surgical intensive care unit patients such as open heart and thoracotomy patients; familiar with balloon pumps, chest tubes, central lines, etc.
Education
Bachelor's degree - Nursing
University of the Incarnate Word
San Antonio, TX08.2000
Skills
- Experience in conducting utilization reviews
- Team leadership
- Clear interpersonal communication
- Process improvement
- Patient care coordination
- Clinical evaluation
- Outpatient care coordination
- Detail-oriented approach
- Efficient multitasking
- Effective clinical decision-making
- Adaptability and flexibility
- Training and mentoring
Certification
Compact State Nurse License
- Additional RN Licenses: CA, NV
Work Availability
monday
tuesday
wednesday
thursday
friday
saturday
sunday
morning
afternoon
evening
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Timeline
Supervisor, UM Prior Authorizations
Molina Healthcare Inc
12.2022 - 02.2026
RN Care Advisor – Utilization Management
Evolent Health
01.2022 - 12.2022
Care Review Clinician - Prior Authorization Nurse
Molina Healthcare
12.2020 - 01.2022
Clinic Team Lead
Health By Design
05.2017 - 12.2020
Nurse Educator and Staff Nurse
Health By Design, a Medici Company
01.2011 - 04.2017
Nurse Manager & Assistant Administrator
Health By Design
04.2008 - 04.2010
Staff Nurse
Health By Design
08.2007 - 04.2008
Staff Nurse, PreOp/PACU/Procedure Room
Sonterra Endoscopy Center
06.2005 - 12.2006
Staff Nurse, Post Anesthesia Care Unit
Methodist Ambulatory Surgical Center
05.2004 - 06.2005
Clinic Staff Nurse
PRMA of South Texas
04.2003 - 05.2004
Staff Nurse, Recovery Room (PACU)
Northwest Florida Surgery Center
03.2001 - 04.2003
Staff Nurse, Intensive Care Unit
Williamsburg Community Hospital
07.2000 - 03.2001
Staff Nurse, Intensive Care Unit
Baptist Medical Center
01.1998 - 07.2000
Bachelor's degree - Nursing
University of the Incarnate Word