Summary
Overview
Work History
Education
Skills
Professional Memberships & Volunteer Work
Timeline
Generic

Kimberly Merlin

Canton

Summary

Results-oriented RN with over 20 years of experience in acute and post-acute care, specializing in utilization review and clinical appeals. Proven expertise in Interqual and discharge planning, effectively reducing denial rates and ensuring compliance with medical necessity standards. Strong ability to collaborate across functions and implement data-driven process improvements.

Overview

10
10
years of professional experience

Work History

RN Clinical Denial Specialist

Northside Hospital
Atlanta
05.2023 - Current
  • Processed and managed clinical denials for inpatient and outpatient claims, ensuring payer guideline compliance.
    Analyzed utilization management data to identify trends and collaborate with stakeholders for resolution.
    Drafted and submitted high-quality clinical appeals supported by evidence-based guidelines.
    Streamlined appeal workflows, reducing denial overturn time through staff training on documentation practices.

RN Care Coordinator

Northside Hospital
Canton
05.2017 - 05.2023
  • Assessed patient treatment needs and developed interdisciplinary care plans.
    Coordinated care transitions across units and facilities to optimize outcomes and reduce readmissions.
    Facilitated team meetings while monitoring quality metrics for compliance and service excellence.
    Supported staff performance reviews and ensured accurate patient documentation for regulatory reporting.

ICU/PCU/Case Manager RN

North Fulton Hospital
Roswell
05.2015 - 05.2017
  • Facilitated collaboration among clients, families, caregivers, and agencies to address client needs. Participated in interdisciplinary team meetings to evaluate and discuss treatment options. Provided information on local support groups to assist family members effectively. Maintained case records and documentation in compliance with agency guidelines.

Education

Master of Science - Nursing

Chamberlain College of Nursing
11-2022

Bachelor of Science - Nursing

Chamberlain College of Nursing
10-2017

Associate of Applied Science - Nursing

Pensacola State College
05-2005

Skills

Clinical Denials & Appeals
Interqual Criteria
Medical Necessity Defense
Utilization Management
Case Management & Discharge Planning


Data Analysis & Reporting
Care Coordination
Interdisciplinary Collaboration
EMR & EHR Proficiency (Cerner)

Professional Memberships & Volunteer Work

  • Member, American Nurses Association (ANA) & Georgia Nurses Association (GNA)
  • Volunteer, Shared Governance & Employee Giving Ambassador

Timeline

RN Clinical Denial Specialist

Northside Hospital
05.2023 - Current

RN Care Coordinator

Northside Hospital
05.2017 - 05.2023

ICU/PCU/Case Manager RN

North Fulton Hospital
05.2015 - 05.2017

Master of Science - Nursing

Chamberlain College of Nursing

Bachelor of Science - Nursing

Chamberlain College of Nursing

Associate of Applied Science - Nursing

Pensacola State College

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Kimberly Merlin