Open to opportunities

Mary Kavanaugh

@marykavanaugh

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Experienced clinical appeals specialist and nurse with deep utilization review expertise.

United States

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What I'm looking for

I seek a clinical appeals or utilization review role where I can apply InterQual expertise, manage high-volume appeals, improve processes, and mentor staff in a collaborative, quality-focused organization.

I am an experienced clinical appeals specialist and licensed practical nurse with over 20 years working across payor, provider, managed care, and independent review settings. I synthesize complex medical data into concise, accurate summaries to achieve favorable outcomes for members and providers.

My background includes utilization review, EHR chart abstraction, InterQual expertise, and full life-cycle claim and appeal management across Medicare, Medicaid, and commercial payors. I have led appeal coordination, authored clinical appeal letters, and adjudicated state and federal-level external appeal processes.

I have served as a clinical liaison, nurse review coordinator, and educator — developing training programs, supervising peer reviewer panels, and ensuring accessibility of written rationales using readability tools. I consistently meet quality and productivity goals in high-volume environments and act as a subject-matter expert on payer criteria and preauthorization portals.

I hold an associate degree and LPN license, and I am authorized to work in the U.S. I seek to bring clinical judgment, appeals strategy, and process improvement skills to roles that value accuracy, clear communication, and measurable outcomes.

Experience

Work history, roles, and key accomplishments

Current

Clinical Appeals Coordinator

Current

Sentara Health Plan

Jun 2024 - Present (1 year 8 months)

Manage large caseload of Medicaid appeals, perform clinical research and analysis, and produce professional appeal responses meeting DMAS and federal timeliness and regulatory requirements; facilitate state fair hearings as needed.

InterQual Regulatory Compliance Case Management Legal DMAS Hearings Clinical Research

Clinical Appeals Specialist

Virtual Business Office Associates

Aug 2023 - Apr 2024 (8 months)

Determined medical necessity using InterQual and payer criteria, composed evidence-based appeals for reconsideration, and planned second-level appeals following PwC policies.

InterQual Medical Necessity Criteria literature review Policy Implementation

Nurse Review Coordinator

National Medical Reviews, Inc.

Jan 2022 - Aug 2023 (1 year 7 months)

Served as primary clinical liaison for clients and peer reviewers, coordinated case review activities and hearings, developed training for nurses, and ensured plain-language rationales and timely external appeal communications.

Peer Review Training Development Flesch Kincaid Readability Case Management Quality Improvement

Clinical Appeals Specialist

Parallon / HCA Hospitals

Aug 2015 - Dec 2021 (6 years 4 months)

Composed clinical appeal letters and determined medical necessity using InterQual; served as Anthem AIM portal superuser for multi-specialty preauthorizations and consistently met productivity and quality targets.

InterQual Anthem AIM Productivity

Utilization Review Nurse

Coventry Health / Kepro

Oct 2013 - Jul 2015 (1 year 9 months)

Conducted utilization review and HEDIS abstraction across Medicaid and commercial lines using Atrezzo and InterQual criteria, and performed on-site reviews for behavioral health organizations.

Utilization Review HEDIS Abstracting InterQual

Nurse Educator

Covenant Woods

Mar 2014 - Feb 2015 (11 months)

Administered the learning management system and delivered education and orientation for 250+ staff, developing a weeklong themed orientation and required regulatory training to meet CARF standards.

CARF Staff Development Curriculum Design