director medicare clinical appeals resume example with 20+ years of experience

Jessica Claire
, , 609 Johnson Ave., 49204, Tulsa, OK 100 Montgomery St. 10th Floor
Home: (555) 432-1000 - Cell: - - : - -

Results-focused healthcare professional with strength in [Skill], [Task] and [Task]. Proactive leader with strengths in communication and collaboration. Proficient in leveraging [Area of expertise] and [Area of expertise] knowledge to promote [Result]. Adept at managing concurrent objectives to promote efficiency and influence positive outcomes. [Job Title] with talent for [Task] and [Task]. Strong knowledge of [Area of expertise] and [Area of expertise]. Communicative and team-oriented with proficiency in [Software]. Proven history of fostering [Action] to meet team, individual and management objectives.

  • Operations oversight
  • Sound judgment
  • Performance improvements
  • Working collaboratively
  • Cross-functional team management
  • Compliance with regulatory guidelines
09/2019 to Current
Director, Medicare Clinical Appeals Atlantic Health System Livingston, NJ,
  • Administer executive supervision, exercising independent judgment to select proper course of action in policies and procedures over clinical staff.
  • Evaluate operational trends and proactively adjusted strategies to maintain alignment between performance and objectives..
  • Improve training to reduce knowledge gaps and eliminate performance roadblocks and also working with business partners.
  • Plan daily operational strategies, including delivery routing, team workflows and promote initiatives.
  • Motivate and support staff completing work to increase work quality and team productivity.
  • Review and participate budget reports with finance and actuarial teams to keep information current and accurate to ensure staffing needs are met.
  • Generated and review reports to assess performance and adjust workflows to realign to ensure targets and business goals are met.
07/2017 to 09/2019
Supervisor, Medicare Appeals Aetna, CVS Health City, STATE,
  • Developed clinical staff with regular evaluations and annual feedback sessions.
  • Facilitated orientation, competencies and skills validation processes for [Job title]s.
  • Maintained compliance with guidelines such as HIPAA and OSHA.
  • Managed team of [Number] registered nurses, [Number] licensed practical nurses and [Number] certified nursing assistants.
  • Coordinated and led in-services to facilitate nursing leadership development and career growth.
  • Fostered improved communication with contractors to promote regulatory compliance.
  • Worked closely with executives to administer operations, staff, resources and budget management.

09/2009 to 07/2017
UM Nurse Consultant/Clinical Team Lead Aetna, CVS Health City, STATE,
  • Responsibilities include, but not limited to, reviewing inpatient admissions to assure appropriate level of care and coordinating with physicians, staff, and facilities regarding patient care.
  • Review the patients’ inpatient plan of care and work with the facility case managers and discharge planners to meet the patients post discharge needs.
  • Working closely with the health plan medical directors to monitor clinical activities for inpatient members and identify alternative levels of care as part of the utilization review process.
  • Precepting for new hires and creating assisted in developing new orientation training manual and checklist as part of Clinical Team Lead responsibilities.
  • Coordinating daily MD rounds conducting complex clinical case reviews with Senior Medical Directors and leadership teams.
06/2001 to 09/2009
Registered Nurse UPMC Presbyterian Shadyside Hospital City, STATE,
  • Responsibilities included, but not limited to, all aspects of nursing care for post multivisceral transplant patients, post heart bypass surgical patients on a telemetry unit, caring for critically ill patients on a Medical Intensive Care Unit (MICU), and currently working in the Emergency Department at UPMC Shadyside.
  • Duties also included assisting MD with procedures such as central line insertion, endoscopy, intubation and bronchoscopy.
  • Trained and experienced in caring for patients on Continuous Venous to Venous Hemodialysis (CVVHD), charge nurse responsibilities, responding to emergency situations or CODES throughout the hospital when necessary, serving as a preceptor to new hires, and a member of the Customer Service Committee in the Medical Intensive Care Unit.
Expected in 09/2009 to to
Bachelor of Science: Nursing
Waynesburg University - Waynesburg, PA,
Expected in 05/2001 to to
Associate of Science: Nursing
Community College of Allegheny County - Pittsburgh, PA,

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Resume Overview

School Attended

  • Waynesburg University
  • Community College of Allegheny County

Job Titles Held:

  • Director, Medicare Clinical Appeals
  • Supervisor, Medicare Appeals
  • UM Nurse Consultant/Clinical Team Lead
  • Registered Nurse


  • Bachelor of Science
  • Associate of Science

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