Michelle Greaves
Thompson’s Station,TN
Summary
Passionate and dedicated professional with a broad range of healthcare experience in leadership and clinical education, currently in the Senior Clinical Manager of Appeals and Denials role at a data-driven and patient-centric organization, seeking an opportunity to utilize expertise in PAC Management, CMS guidelines, audit preparation/ participation, leadership, training and education and relationship management.
Overview
15
15
years of professional experience
1
1
Certification
Work History
Appeals and Denials Senior Clinical Manager
naviHealth
08.2021 - 05.2024
- Serving as Subject Matter Expert (SME) in Appeals and Denials related processes for Home Health, SNF, IRF and LTACH levels of care with focus on first PAC setting, length of stay (LOS) and preventing readmissions while ensuring compliance with all federal and state regulations, contractual obligations, accreditation standards, and client requests
- Generating universe reporting and preparing for and participating in monthly, quarterly and ad hoc health plan, NCQA and CMS audits
- Responsible for development of department's root cause analyses and remediation plans
- Completing Senior Manager Level internal quality documentation and process review and providing actionable feedback to improve results
- Responsible for creating, updating and maintaining department's policies and and standard operating procedures (SOP)
- Recognizing opportunities for operational process improvements as department's Lean Methodology SME and driving change that will impact and improve overall utilization, provider, client and member experience and colleague satisfaction
- Ensuring consistency in process across markets by collaborating with Appeals and Denials leadership, Compliance team, and Market and Pre-Service Leadership
- Collaborating with Learning and Development leadership to build and implement onboarding, training and precepting/mentoring as it relates to Appeals and Denials Coordinator and Manager roles
- Supporting and participating in monthly Client meetings by providing feedback on data trends and identified cases and collaborating with Market leadership and Provider Relations teams across markets
- Participating in Health Plan collaboration for creating applicable Appeals and Denials workflows by supporting as SME in clinical model, authorization process, organizational structure and learning and development
- Collaboration with BFCC-QIO representatives and Market leadership to align on QIO Determination rationales and institute process improvement as a result
- Supporting Appeals and Denials letter template (IDN and DENC/DNOD) enhancements to create consistency and improve efficiencies for Appeals and Denials Coordinators
- Identifying and supporting Appeals and Denials Product and reporting enhancements to create consistency and improve efficiencies for Appeals and Denials Coordinators
- Supporting Market leadership by identifying trends and offering solutions by utilizing reporting as it relates to Appeals and Denials team functions
- Collaborating with Appeals and Denials leadership and Central Operations Performance team to develop staffing model, team structure, productivity dashboard and evaluate performance by monitoring Appeals and Denials Coordinator’s productivity, schedules, training time or other disruption in work and overtime
- Collaborating with Clinical Quality team to create and implement inter-rater reliability process for Clinical Managers to ensure Appeals and Denials team maintains compliance required for monthly quality reviews
- Supporting remote team of over one hundred Appeals and Denials Coordinators by maintaining high-performing colleagues and by cultivating a strong internal culture designed around colleague recognition, colleague engagement, motivation, providing feedback and education and accountability
Appeals and Denials Clinical Team Manager
naviHealth
08.2020 - 08.2021
- Handle day-to-day management of assigned Appeals and Denials Coordinators
- Participate in Monthly Market Reviews to discuss trends and key metrics
- Participate in Quarterly Performance reviews with Clients to discuss trends and key metrics
- Collaborate with leaders to identify and implement process improvement
- Ensure compliance with all federal and state regulations and client requests
- Facilitate weekly team meetings to provide updates to workflows
- Facilitate bi-weekly colleague meetings to discuss Clinical Record reviews and Performance
- Cultivate strong internal team culture designed around recognition, feedback, motivation and accountability
- Participate in interviewing, hiring and successful onboarding of new Appeals and Denials Coordinators
- Participating in stretch assignments as assigned by Senior Leadership as department's Post-Acute SME
Lead Clinical Trainer
naviHealth
06.2019 - 08.2020
- Worked closely with department's Senior leadership to assist in coordinating and improving training
- Lead team of ten Clinical and non-Clinical Trainers to ensure training needs were met company wide
- Successfully migrated from robust in-person Clinical onboarding model to an effective fully virtual onboarding model
- Collaborated with technical writers and instructional designers to create clinical and non-clinical corporate training programs
- Utilize expertise in adult learning model to ensure training programs were conducive to all new and existing colleagues
- Obtained Virtual Instructor Lead Training (VILT) certification
Clinical Trainer
naviHealth
08.2018 - 06.2019
- Assisted in design, development and facilitation of clinical training programs
- Delivered clinical training to hundreds of new and existing clinical colleagues during times of extreme organizational growth
- Provided subject matter expertise on training aspects of clinical operations
- Established effective working relationships with all levels of staff and management
- Utilized creative and adaptive teaching techniques to accommodate adult learning
Field Staff Team Lead
naviHealth
07.2016 - 08.2018
- Worked closely with Management to assist in daily operation of team of clinical colleagues
- Subject matter expertise in Post-Acute Care management and client, member, and provider engagement and satisfaction
- Served as a mentor, resource and role model to peers
- Developed educational programs to promote continued learning experiences
- Served as subject matter expert in wound care and provided cross-departmental education
- Developed and piloted new processes and procedures within assigned market
Skilled Inpatient Care Coordinator (SICC)
naviHealth
07.2014 - 07.2016
- Performed assessments of members using clinical skills and appropriate measurement tools
- Performed Utilization Management Functions for members within market
- Collaborated effectively with clinical team to establish optimal, individualized plan of care
Registered Nurse Supervisor
The Greenery Specialty Care Center
05.2014 - 07.2014
- Directed and supervised nursing personnel to ensure all resident and family needs were met
- Completed assessments, order entry and addressed lab results of new patient admissions
Assistant Director of Nursing
Country Meadows Nursing Center
10.2013 - 05.2014
- Directed and supervised nursing personnel of a two- hundred bed skilled nursing facility to ensure all resident and family needs were met
- Responsible for facility's wound care team which included wound care physician and LPNs by assessing, treating and documented onset and progression of patient wounds
- Responsible for facility's staffing of nursing personnel
- Responsible for interviewing and hiring new nurses and nurse's aids
Registered Nurse
Country Meadows Nursing Center
01.2011 - 01.2013
- Responsible for afternoon shift assignment on acute rehab unit by performing admission assessments, collaborating with physicians, administering medications, and ensure chart documentation integrity
- Collaborating with nursing leadership team and assisting in shift coverage to ensure best patient outcomes
Registered Nurse
Care Plus Home Health
01.2010 - 01.2011
- Complete start of care assessments to new Home Health Patients
- Performing medication and feeding administration for assigned Home Health Patients
- Performing wound care assessment and treatment for assigned Home Health Patients
- Provided patient and family education on medication and feeding administration, wound care maintenance
- Collaborated with therapists and social services to coordinate patient care
Registered Nurse
Jefferson Regional Medical Center
01.2009 - 01.2011
- Responsible for patient assignment on a step-down cardiac rehab unit by performing admission assessments, collaborating with physicians, administering medications, and ensure chart documentation integrity
- Collaborating with nursing leadership team and assisting in shift coverage to ensure best patient outcomes
- Specialized in caring for post cardiac catheterization patients
Education
Bachelor of Science in Nursing (BSN) -
Wheeling Jesuit University
05.2009
Skills
- Audit Preparation and Participation
- Policy and SOP Maintenance
- Clinical Leadership
- Post Acute Care Utilization Management
- Medicare Guidelines
- Lean Methodology
- Process Improvement
- Documentation Integrity
- Learning and Development
- Wound Care
Certification
- RN licensure state of Tennessee, Active
- Health and Life Coach Certification
- Certified Wound Care Nurse, Current
References
References upon request
Timeline
Appeals and Denials Senior Clinical Manager
naviHealth
08.2021 - 05.2024
Appeals and Denials Clinical Team Manager
naviHealth
08.2020 - 08.2021
Lead Clinical Trainer
naviHealth
06.2019 - 08.2020
Clinical Trainer
naviHealth
08.2018 - 06.2019
Field Staff Team Lead
naviHealth
07.2016 - 08.2018
Skilled Inpatient Care Coordinator (SICC)
naviHealth
07.2014 - 07.2016
Registered Nurse Supervisor
The Greenery Specialty Care Center
05.2014 - 07.2014
Assistant Director of Nursing
Country Meadows Nursing Center
10.2013 - 05.2014
Registered Nurse
Country Meadows Nursing Center
01.2011 - 01.2013
Registered Nurse
Care Plus Home Health
01.2010 - 01.2011
Registered Nurse
Jefferson Regional Medical Center
01.2009 - 01.2011
Bachelor of Science in Nursing (BSN) -
Wheeling Jesuit University
- RN licensure state of Tennessee, Active
- Health and Life Coach Certification
- Certified Wound Care Nurse, Current
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