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Kepro - Clinical Appeals Specialist Resume Example

Olivia Sanchez
XXXX XXXXXXXXX XXXX XX, Mechanicsville, VA 23111
Professional Summary

Extremely self-directed and detail oriented Clinical Appeals Specialist seeking a position as a RN Quality Manager.  Passionate  and motivated with a drive for excellence.  Licensed as a Registered Nurse in the Commonwealth of Virginia and Compact States.

  • Knowledgeable and skilled in McKesson InterQual
  • Experienced in Microsoft Word, Excel, Access & PowerPoint
  • Time Management
  • Critical Thinker
  • Complex Problem Solving
  • Skilled Researcher
Clinical Appeals Specialist Mar 2013Present KEPRO Richmond, VA
  • Research and process Traditional Service Appeals and ensure that they are completed to meet DMAS turn around times
  • Review and interpret patient records and compare against criteria and DMAS requirements to determine medical necessity and appropriateness of care
  • Ensure appeal decision is clearly and properly recorded in Atrezzo
  • Interact with physician consultants, Informal Appeal Agents and DMAS Contract Monitors
Nurse Reviewer Feb 2011Mar 2013 KEPRO Richmond, VA
  • Perform pre-authorization duties for Behavioral Health, Imaging and Intensive Rehabilitation
  • Reviews are completed in a timely manner and in accordance with KEPRO and DMAS standards
  • Appropriate number of reviews are completed daily to meet contractual turn around timeliness
Nurse, Disease Management, Complex Care Nov 2009Dec 2010 Anthem Blue Cross Blue Shield Richmond, VA
  • Perform telephonic health coaching for members, across multiple medical condition lines, for health improvement/management/triage programs
  • Coordinate internal and external resources to meet member's needs

Quality Improvement Coordinator Oct 2000Sep 2009 Southern Health Services, Inc. Richmond, VA
  • Perform Quality Improvement studies as they relate to trends identified via utilization review activities and HEDIS results
  • Maintain accurate documentation of all Quality Improvement activities
  • Conduct HEDIS review audits and tabulate results in accordance with NCQA standards
  • Assist in preparing annual QI program evaluation and work plan
Pre-Authorization Consultant Aug 1999Oct 2000 Southern Health Services, Inc Richmond, VA
  • Responsible for implementing and coordinating all utilization management functions relating to preauthorization of outpatient testing and surgery
  • Utilize McKesson InterQual and other established criteria to authorize diagnostic testing, inpatient and outpatient surgery and other ambulatory services
Medical Care Consultant Jul 1998Jul 1999 Careworks Richmond, VA
  • Perform telephonic case management for state workers who sustain a work related injury
  • Review medical records to assist in determining causation of injury
  • Communicate with physician offices and employers to negotiate modified duty for injured workers
Certificate, Legal Nurse Consultant Jul 1999 National Center for Paralegal Training Atlanta, GA
Associate of Science : Shipbuilding Jun 1985 Solano Community College Suisan, CA
Diploma-Nursing Jun 1976 Pilgrim Psychiatric Center - School of Nursing West Brentwood, NY

Prior Certification: Certified Case Manager  1993-1998

Prior Affiliations:

VARN - Virginia Association of Rehabilitation Nurses

CMSA - Case Management Society of America

CVAHQ - Central Virginia Association of Healthcare Quality

AALNC - American Association of Legal Nurse Consultants

Central Virginia Chapter of AALNC - Charter Member

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Resume Details

This is a real resume for a Clinical Appeals Specialist in Mechanicsville, Virginia with experience working for such companies as Kepro, Anthem Blue Cross Blue Shield, Southern Health Services. This is one of the hundreds of Clinical Appeals Specialist resumes available on our site for free. Use these resumes as templates to get help creating the best Clinical Appeals Specialist resume.

Previous Companies:

  • Anthem Blue Cross Blue Shield
  • Southern Health Services

Previous Job Positions:

  • Clinical Appeals Specialist
  • Nurse Reviewer
  • Nurse
  • Disease Management
  • Complex Care


  • National Center for Paralegal Training
  • Solano Community College
  • Pilgrim Psychiatric Center - School of Nursing

Level of Education:

  • Associate of Science

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