Samantha Ream, Bsn, Rn Email & Phone Number

Philadelphia, Pennsylvania, United States

The Medical Policy Coordinator is responsible for developing and maintaining medical policies which conform to accepted medical practice standards, researching and developing clinical rationale for annual and quarterly medical code updates, and responding to clinical inquiries.• Develops and maintains new and existing medical policies conforming to accepted medical practice standards and in accordance with evidence based principles of medicine, Company benefit structure, state and federal mandates and other appropriate sources.• Presents Medical Policy Bulletins to appropriate workgroups and committees and revises documents according to recommendations.• Researches and develops clinical rationale for annual and quarterly medical code updates.• Serves as a resource to company associates, and personnel of affiliated companies, by answering clinical inquiries using medical literature, company policy, and other appropriate resources.• Assists in developing written responses to questions of a clinical nature received by the departmental medical director and other management staff.• Establishes goals for assignments in accordance with department and Company operational objectives and seeks feedback on performance. Ensures that assignments are scheduled and completed in an accurate and timely manner.• Maintains detailed knowledge of the status of all assignments and routinely updates the Supervisor, Medical Policy and other members of the management team, as appropriate.• Serves as a liaison to other departments of the Company and represents the department at meetings and on work groups as assigned by management. Leads multidisciplinary workgroups to resolve complex issues as required.• Interacts with all levels of management within the Company and with outside consultants and other organizations.• Performs additional related duties as assigned.

Philadelphia, Pennsylvania, United States

• Coordinates all levels of medical, pharmacy, and mental health appeals• Performs review of medical documentation using Interqual criteria or Medical Policy to determine if the requested service can be approved• Ensures all assigned appeals are completed within the compliance timeframes• In accordance with NCQA guidelines, generates appropriate correspondence to inform the applicable parties of the appeal determination• Completes disclosures of clinical documents as applicable and in accordance with corporate policies• Maintains knowledge of NCQA standards, Interqual Criteria, as well as applicable state and federal government regulations related to appeals• Works collaboratively with peers and other associates both within the Appeals Department and other business areas

Warminster, Pennsylvania

• Coordinates case review activities consistent with corporate policy and client-specific procedures• Determines the types of review, peer clinical reviewer specialties and selects peer clinical reviewers.• Ensures that the case is forwarded to, and received by, the peer clinical reviewer in a timely manner• Monitors case due date and takes steps to ensure timely return to the client• Ensures that the peer clinical reviewer’s determination is complete and oversees transcription• Notifies the client and other designated parties of the final determination• Interacts on a daily basis with the Chief Medical Director, as needed, to complete case reviews• Serves as the primary liaison and resource for clients and peer clinical reviewers• Assists in the recruitment of new peer clinical reviewers• Serves as a member of the Quality Management Committee• Actively participates in the orientation and training of new Review Coordinator Assistants

Horsham, Pennsylvania

• Confers with internal and/or external customers to provide prompt and accurate information about products and/or services by various methods of communication while promoting customer loyalty for the client.• Ensures customer satisfaction and loyalty by consulting with customers, assisting customers, and resolving a wide variety of customer requests, inquiries, and complaints.• Resolves customer questions and concerns effectively and efficiently by actively listening, communicating clearly and concisely, and assuring customer understanding.• Documents customer interactions and transactions, recording details of inquiries, complaints, comments and actions taken, to include Adverse Events.• Obtains and examines all relevant information to assess validity of complaints and to determine possible causes. Outbound calls made that are related to the product or service, and/or in follow-up to a customer inquiry.• Ensures that production and quality expectations are achieved and meet or exceed all client contractual requirements.

Fort Washington, Pa

• Provide drug and/ or medical device information to patients and caregivers while actively resolving customer questions and concerns• Identify adverse events and product complaints as outlined by client guidelines • Accurately collect information required by individual programs and correctly capture in specific program databases while managing and/ or utilizing all telecommunication effectively.• Develop and deliver training materials to current and new hire associates for designated client including internal, and client utilized applications, product knowledge, medical information, and patient centered customer service. • Ensure associates exceed the performance standards of both the company and the client requirements, this includes, but is not limited to client certification.

Abington, Pa

• Preform as a member of a multi-disciplinary healthcare team to provide patient centered care on an inpatient rehabilitation unit • Effectively interact with patients to access individualized needs while obtaining and conducting thorough patient assessments• Accurately document patient information in a computerized charting system and/ or hand written documentation as per hospital policy and procedure. • Assist patients with activities of daily living and integrated fall risk procedures• Dispense patient medication while following all safety checks to ensure accuracy and limit medication errors

Bachelor’S Degree, Registered Nursing/Registered Nurse, Gpa: 3.78

Diploma, Registered Nursing/Registered Nurse, Cum Laude

Disploma, Cosmetology/Cosmetologist, General

Licensed Cosmetologist

Psychology, Dean’S List