MELISSA VILLA
Los Angeles
Summary
Registered Nurse with over 6 years of experience in utilization management and prior authorization, excelling in medical policy compliance and health plan guidelines. Expert in medical necessity review with retrospective and prospective utilization management. Robust organizational and communication skills to provide top-tier coding accuracy and medical policy compliance . Focused on meeting clinical care appropriateness guidelines due to medical necessity.
Overview
9
9
years of professional experience
Work History
Nurse Reviewer Senior
Carelon Medical Benefits Management
10.2018 - Current
- Conducts preauthorization requests to assess medical necessity of procedures, out of network services, and appropriateness of treatment.
- Conducts initial medical necessity review of exception preauthorization requests for services requested outside of the client health plan network.
- Ensures proper documentation, provider communication, and telephone service per department standards and performance metrics.
- Knowledge in Utilization Management Guidelines, ICD-9 and CPT-4 coding.
- Knowledge in managed health care including HMO, PPO, and POS plans.
- Serve as mentor and coach new and lower level associates.
Aesthetic Registered Nurse
New Look Skin Center
04.2016 - 10.2018
- Ensured patient safety by reviewing medical records prior to laser treatments
- Augmented patient understanding through pre/post care instructions
- Stayed abreast of new company policies and equipment guidelines
Education
RN TO BSN PROGRAM -
West Coast University-Los Angeles
North Hollywood, CaADN RN PROGRAM -
Los Angeles Trade Technical College
Los Angeles, CaSkills
- Prior Authorization
- Utilization Management
- Prospective Utilization Review
- Medical Necessity Clinical Review
- ICD-9-CM
- ICD-10-CM
Roles And Responsibilities
- Manage pre-authorization requests, ensuring compliance with health plan criteria.
- Supporting the utilization management team with complex case reviews.
- Evaluates clinical information against established clinical criteria and health plan guidelines.
- Meticulously assess retrospective and prospective requests against health plan criteria, ensuring compliance and medical necessity.
- Mentor team members on clinical review of cases while maintaining HIPAA compliance.
- Stayed abreast of new health plan policies and guidelines for medical necessity.
- Knowledge with ICD-9, ICD-10, and HCPCS coding.
License
California RN License 751805
Timeline
Nurse Reviewer Senior
Carelon Medical Benefits Management
10.2018 - Current
Aesthetic Registered Nurse
New Look Skin Center
04.2016 - 10.2018
RN TO BSN PROGRAM -
West Coast University-Los Angeles
ADN RN PROGRAM -
Los Angeles Trade Technical College
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