MELODY WALLACE
Little River
Summary
Proactive and goal-oriented professional with excellent time management and problem-solving skills. Known for reliability and adaptability, with swift capacity to learn and apply new skills. Committed to leveraging these qualities to drive team success and contribute to organizational growth.
Overview
13
13
years of professional experience
Work History
Prior Authorization RN
UnitedHealthcare Community Plan
05.2021 - Current
- Perform clinical reviews, which require decision making related to interpretation of state and federal mandates, applicable benefit language, and consideration of relevant clinical information
- Proficient in using clinical criteria and medical policy guidelines
- Serve as a member of a team with specific individual and team performance metrics
- Communicate in writing and verbally, all forms of benefit determinations including decisions regarding coverage guidelines, contractual limitations, and reimbursement determinations
- Manage caseload of Prior Auth Escalations within Lines of Business to ensure care delivery for our members
- Solid working knowledge of the health insurance industry, products and service and the managed care environment
- Work independently and collaboratively with Medical Directors and other business partners
- Flexibility to adapt to changing environment and varied case volume
- Other duties as assigned by leadership
PRN Hospice RN
Hospice Care of South Carolina
07.2019 - Current
- Performed triage assessment to understand immediate needs and informed physician and case manager.
- Administered medications, provided wound care, recorded vital signs, and documented all intervention.
- Ensured patient was as comfortable, pain-free, and symptom-free as possible during end of life care.
- Continually documented status changes and logged recommendations aimed at improving comfort level.
PRN Hospice RN
Encompass Hospice
12.2017 - 04.2019
- Performed triage assessment to understand immediate needs and informed physician and case manager.
- Administered medications, provided wound care, recorded vital signs, and documented all intervention.
- Ensured patient was as comfortable, pain-free, and symptom-free as possible during end of life care.
- Continually documented status changes and logged recommendations aimed at improving comfort level.
RN Case Manager
Health South RIOSA
04.2017 - 05.2018
- Managed and directed resource utilization to achieve highest quality outcome during rehabilitation.
- Actively coordinated services and managed issues in admission, discharge, conference and plan of care.
- Served as advocate for the patient and ensured patient rights and regulations were adhered to.
- Quickly assessed, prioritized, and executed plan of care and made contact for all level of services needed.
RN Hospice Case Manager
Alamo Hospice
04.2017 - 12.2017
- Communicated daily with interdisciplinary team including physicians, nurses, social, and other services.
- Received assessment from the triage nurse to determine if immediate visit and services were needed.
- Determined what level and type of counseling, education, and care the patients’ caregivers needed.
- Helped to familiarize caregivers with aspects of daily care and adapt in accordance with changing needs.
Director of Nursing
Benevolent Hospice of Houston, LLC
09.2016 - 11.2016
- Supervised and supported twelve clinical staff-members and maintained caseload of ten patients.
- Directed implementation of approved work methods and complied with regulations of Department of Aging and Disability, Center for Medicare/Medicaid, the State of Texas, and the Joint Commission.
- Encouraged and counseled patients and families to assist in meeting patient and caregiver needs.
- Oversaw fall, medication, and high alert binders while acting as preceptor for students and personnel.
RN Hospice Case Manager
Benevolent Hospice of Houston, LLC
01.2016 - 09.2016
- Developed, implemented, revised, and managed interdisciplinary care plan of over twenty patients.
- Performed physical assessment, pain assessment and management, and symptom management.
- Maintained and updated hospice aide care plan and coordinated hospice services with other disciplines.
- Participated in interdisciplinary group and clinical staff meetings and consulted with Medical Director.
RN-Tele/Med-Surg
Christus Santa Rosa Westover Hills
05.2015 - 01.2016
- Assessed, implemented, delegated, and evaluated total nursing care in accordance with policy.
- Provided direct patient care for over 100 patients over the course of six months.
- Coordinated effectively with other shifts and departments for optimal continuity of care.
- Provided clinical supervision for entry level nurses and assisted in their professional development.
RN-PACT
STXVHS-Frank Tejada Outpatient Clinic
02.2014 - 04.2015
- Served as telephonic assessment case manager, chronic disease management, and triage nurse.
- Communicated with providers, social service, behavioral health, and patient representatives.
- Served as team leader supervising LVNs and directed staff in patient care and prepared shift schedules.
- Coordinated with staffing agency by providing the daily nurse schedule and refined workflow process.
RN-PACT
VA N. Texas Healthcare System/FWOPC
05.2013 - 02.2014
- Provided indirect patient care as part of interdisciplinary team and served as clinical resource expert.
- Screened patients for social services, home care, sought consultation and made referrals as appropriate.
- Evaluated needs and facilitated patient’s ability to learn the principles of self-care.
- Oversaw patient care documentation within Computerized Patient Record System (VA-CPRS).
Education
Bachelor of Science - Management of Human Resources
New School for Social Research
New York, NY01.1991
Bachelor of Science - Nursing
Coastal Carolina University
Myrtle Beach, SC01.2021
Associate - Nursing
Mohawk Valley Community College
Utica, NY01.2009
Skills
- Clinical review
- Benefit determination
- Medical policy guidelines
- Case management
- Resource utilization
- Interdisciplinary collaboration
- Triage assessment
- Care coordination
- Critical thinking
- Licensed RN
- Precepting
- High level of autonomy
Accomplishments
- Training - Trained RNs new to the team in documentation, state mandates and policies, and procedures to ensure consistent quality prior authorization case reviews.
Timeline
Prior Authorization RN
UnitedHealthcare Community Plan
05.2021 - Current
PRN Hospice RN
Hospice Care of South Carolina
07.2019 - Current
PRN Hospice RN
Encompass Hospice
12.2017 - 04.2019
RN Case Manager
Health South RIOSA
04.2017 - 05.2018
RN Hospice Case Manager
Alamo Hospice
04.2017 - 12.2017
Director of Nursing
Benevolent Hospice of Houston, LLC
09.2016 - 11.2016
RN Hospice Case Manager
Benevolent Hospice of Houston, LLC
01.2016 - 09.2016
RN-Tele/Med-Surg
Christus Santa Rosa Westover Hills
05.2015 - 01.2016
RN-PACT
STXVHS-Frank Tejada Outpatient Clinic
02.2014 - 04.2015
RN-PACT
VA N. Texas Healthcare System/FWOPC
05.2013 - 02.2014
Bachelor of Science - Nursing
Coastal Carolina University
Associate - Nursing
Mohawk Valley Community College
Bachelor of Science - Management of Human Resources
New School for Social Research
Personal Information
Volunteer activities include local animal rescues, 501c3s, and church.