Melissa Mcvey Email & Phone Number

Kansas City, Missouri Area

Review medical records for 1st and 2nd level appeals of denied treatments and services. Appropriately apply clinical judgment and knowledge to overturn denials and approve services as medically necessary. Collaborate with Medical Director regarding complex benefit decisions and uphold denials. * Apply plan brochure language and criteria outlined in internal medical policies, Milliman Care Guidelines, and InterQual to determine medical necessity, appropriate level of care, and coding accuracy. * Audit cases referred by independent agency that oversees the FEHB. Identify process issues during 2nd level appeal reviews to discuss with initial and appeal review teams from GEHA and vendors. Follow up on discrepancies for process improvements. * Recommend process improvements to prevent appeals and implement cost containment strategies. * Assist with revising and updating medical policies to meet current standards of care. Research coverage benefits from Medicare and other major health insurers. * Proficient use of computer applications (internal and external) and programs.

Kansas City, Missouri Area

Collaborate with patients, families, physicians and treatment team to monitor care progression and identify discharge planning needs. Manage daily face-to-face caseload of 25 patients; 60-70 patients on weekends.• Promptly complete and document assessment of patient and support system needs at time of admission. Maintain strict confidentiality of personal information.• Identify high risk factors and evaluate self-care ability. Determine eligibility for external services and document interventions. Discuss barriers during discharge rounds with physicians and team. Collaboratively resolve patient care issues and meet goals while motivating patients to independently make healthy lifestyle choices.• Team healthcare approach with social workers as guided by complex patient needs and reduce duplication of effort.• Act as patient advocate by addressing psychosocial concerns and ensuring access to treatment plan recommendations and available community resources.

Kansas City, Missouri Area

Provided cost-effective method for claim resolution. Handled average 40-50 open cases, generated from several states. Discussed additional details surrounding injury and complaint.• Applied extensive medical knowledge to complex and complicated cases. Conducted review of physician, surgeon, and physical therapist reports for high-level assessments: rotator cuff tears, back sprains, repetitive injuries. Contributed to controlling claim cost through thorough treatment reassessments. • Wrote detailed case reviews and recommendations. Ensured appropriate and cost-effective healthcare services by carefully reviewing the injured worker's needs.

Bentonville, Arkansas

Adjunct Clinical Nursing Instructor leading weekend, 8-hour shift clinical rounds for 22 non-traditional students in fast-track RN program. Enhanced student, and personal, analytic and critical thinking skills. • Taught methodology and theory behind procedures. Educated students in medical treatment plan and evidence-based guidelines. Enhanced understanding of disease process.• Delivered student support in hospital setting and maintained patient safety. Honed analytic talents through part-time adjunct teaching role.

Fayetteville, Arkansas Area

RN in 20-bed intensive care unit and 20-bed coronary care unit caring for patients at a Level 2 Trauma Center with life-threatening conditions or injuries including Neuro, Cardiac, and Surgical emergencies.• Ensured team understanding delivering improved, proactive medical care. Reviewed individual cases, formulated response plans, and communicated special needs to staff. • Collaborated with medical team regarding patient treatment, care, condition, and response. • Explained medications, processes, and treatments. Verified medications and noted physiological and behavioral changes after dosing. Charted, electronically, indicators and vital signs. Identified trending conditions and fluctuations.

Columbia, Missouri Area

Medicine Unit 2007-201224-bed. Caring for patients suffering from conditions including unstable angina, congestive heart failure, chronic obstructive pulmonary disease, chronic kidney disease, end stage liver disease, substance abuse, and behavioral health disorders. Medical/Surgical Unit 2005-200740-bed. Caring for additional general surgery, urology, and orthopedic surgery patients prior to unit split.Short Stay & Step Down Units 2003-200510-bed each. Cross-trained between both units to provide care according to staff needs. Short Stay Unit: minor procedures requiring 2-24 hours observation such as cardiac caths and laparoscopic cholecystectomies. Step Down Unit: providing care to patients leaving the ICU but still requiring closer monitoring or higher level of care than that of a med/surg unit.Student Nurse Tech-Valor 2002-2003

Bsn, Nursing

Mba, Concentration In Health Management