Melissa McVey

Appeals Nurse Consultant @GEHA Health

Kansas City, MO, US

Review medical records for 1st and 2nd level appeals of prior authorization and retrospective requests regarding denied acute care hospital inpatient stays, treatments, and services. Apply clinical 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 in acute care settings, 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 G.E.H.A 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.

University of Missouri-Columbia

BSN

William Woods University

MBA