Prominent skills required to communicate critical information to appropriate leadership regarding various appeals and related issues, implications, and decisions. Report to supervisor/manager of appeals, coordinate, and perform all appeal-related duties. Appeals include requests for decisions regarding denials of medical services as well as pharmaceuticals. Responsible for analyzing and responding appropriately to appeals from members, member representatives, and providers regarding denials for services and denials of payment via oral and written communication; research and apply pertinent medical regulations to determine the outcome of the appeal; oversight and assistance to management staff with resolution(s) of appeal(s) by interpreting medical regulations; reviewing documentation to ensure that all aspects of the appeal(s) are addressed properly and accurately; prepare case files for submission to include writing required case summary on behalf of the plan to support appeal resolution.Excellent prioritization and organizational skills; effectively manage competing priorities and multiple deadlines. Independently make appropriate administrative determinations as to whether a claim should be approved or denied based on the available information and as well as research and, as required, provide written detailed clinical summary reports. Ability to work objectively and provide fact-based answers with clear and concise documentation. Prioritizes workflow consistently, applies key HIPAA and CMS guidelines in daily workflow and meets turnaround times for assigned cases. Ability to multi-task and meet multiple competing deadlines. Ability to work independently and under pressure.

CoolSculpting Consultant-OngoingCertified to provide CoolSculpting the treatment for patients wanting to target visible fat bulges in the submental (under the chin) and submandibular (under the jawline) areas, thigh, abdomen, and flank, along with bra fat, back fat, underneath the buttocks, and upper arm. Advanced Aesthetic Nurse-Ongoing Certified Medical Aesthetics Training for Injectables and Advanced Injectables through National Laser Institute • Cosmetic Injections: Botox, Dysport, and Exomin• Dermal Fillers: Juvederm Ultra, Juvaderm Ultra Plus, Restalyne, Restalyne Lyft, Restalyne Refyne, Restalyne Silk, Restalyne Defyne, Voluma, Volbella, Beletero, Vollure• Injectable Nutrients: Energy, Vibrant, Skinny, Fountain of Youth, PRP Injections, PRP Hair Restoration, PRP Female Rejuvenation shot

• Carry out continuous review of all aspects of patients on their caseload, such as the properly utilizing services, guaranteeing provision of continued skilled need, and tracking homebound status, assessing documentation of medical records, and maintaining interdisciplinary communication and discharge planning.• Perform a complete physical assessment and health history of the patient.• Conduct an initial evaluation of patient and family to identify home care needs.• Formulate a care plan to set goals based on nursing diagnosis and incorporate therapeutic, preventive, and rehabilitative nursing actions.• Accomplish appropriate preventive rehabilitative nursing procedures; and administer medications and treatments as prescribed by the physician.• Offer health care instruction to patients in alignment with the assessment and plan.• Reassess patients within 24 hours after a change in condition or a discharge from an impatient setting.• Handle the financial resources and eligibility under different third-party payer sources, Medicare, and medical.• Supervise licensed vocational nurses (LVNs) and home health aides in compliance with Certified Hospital Admission Program (CHAP) standards and regulatory requirements.• Implement the plan of care for patients and provide appropriate revisions in line with status and needs changes

• Evaluated monthly reports to ensure maintenance of department performance of daily production within established metric expectations.• Directed new clinical and support staff on daily productions.• Collaborated with appropriate departments to identify available resources.• Managed clinical and utilization review to control costs while keeping track of quality of patient care.• Evaluated electronic medical records by assessing the appropriateness of healthcare consumption.• Coordinated with patients, physicians, and insurance providers daily to guarantee effective case management.

• Prioritized and focused on the prevention of sickness and disabilities and early detection and correction of health issues.• Rendered complete health evaluation and determined any abnormal health findings.• Performed mandated health screenings, physicals, and special education assessments.• Created policies and procedures for crises interventions for acute illness, injury, and emotional disturbances.• Handled school and community health services as the point of contact among the community, school, and home.• Supported with the control of communicable diseases through preventative education programs, as well as early detection, surveillance, and reporting of contagious diseases.• Maintained involvement with Child Education Evaluation Team to develop the health individualized education plan (IEP).

• Executed initial and ongoing health evaluations of individual patients and their families by assessing their physical, mental, and environmental status, subsequently conducting nursing interventions based on assessment of need.• Utilized independent emergency measures to counteract adverse health developments while informing and alerting physicians regarding the condition of the patient.• Observed patient health status by tracking and documenting vital signs, blood and urine laboratory values, intake and output, and heart and lung auscultation.• Guaranteed appropriate documentation of patient care and regular communication with the patient, their family, care givers, and physician while instructing and leading the home attendants.