Melanie Ostrosky: Medical Services Manager in the Birmingham Office

When did you start working here? What's your current job title? I joined the American Mining team in February 2006, as a nurse case manager in the Determined Unit of the Claims Department. We recently have expanded our Unit, initiating active, on-site case management in the Birmingham area, in addition to telephonic case management. Due to our expansion, I was asked to lead our Unit as Medical Services Manager.

Tell us about a typical day? What happens when you walk into the office every morning? There is never a typical day in our Unit. Each phone call, e-mail, or task-list item lends to assessing, planning, coordinating and implementing care to our claimant’s, on an individual basis. We usually begin our day with a planning meeting in which we discuss any on-site visits for the day, meetings/conferences to attend and cases needing immediate action. Our duties throughout the day include assisting the claims adjusters with the medical benefit administration of a claim, administering benefits for settled claims with open life-time medical benefits, telephonic and on-site case management, catastrophic case management, assisting claims adjusters with medical fee disputes, utilization/peer review referrals, adjudication of medical bills. Some days we feel as if we have worn many hats, from patient advocate to FBI/DEA investigator (Ha!). We feel we must maintain flexibility and the ability to multi-task throughout the day.

What are the typical claims you review like? Claim reviews vary widely. We might be asked to review a simple sprain/strain or a more difficult injury such as trauma resulting in paralysis. Each injury/condition must be reviewed and a care plan initiated and coordinated with the providers based on severity and intensity of treatment required. No claim is typical. We strive to assist the provider in coordinating a medically reasonable treatment plan in relation to the work injury. Our goal is to work with the provider to ensure quality care, in an effort to promote the best outcome for the claimant, within the scope of compensable benefits.

Where did you go to school? I graduated with a Bachelor of Science in Nursing Degree from the Ida V. Moffett School of Nursing at Samford University in Birmingham Alabama. I graduated in 1987 and have held a license as a Registered Nurse since 1985, at which time I received an Associates Degree in Nursing from the same nursing school. I began my nursing career working with cardiac, medical-surgical, trauma, rehabilitation and oncology patients.

Where did you work before joining us? I left active practice to launch into the managed care, group health insurance arena to pursue positions in utilization review, quality improvement and case management. I have worked for several of the local insurance companies in the Birmingham area. The last position I held was within a company set up somewhat like American Mining. I worked in the home office in Birmingham, with branches throughout the United States.

How are things different than where you worked before? In the positions I have held prior to joining AMIC, the legal aspect of the work comp claim is the difference for me. I have been involved with the medical aspects of care management in the past. Learning the different state laws relating to a work comp claim has been most intriguing for me, due to my interest in the legal field. I have contemplated pursuing legal avenues in the near future to assist with my duties at AMIC.

What would you be doing if you weren’t working here? If I were not working with AMIC, I would probably pursue a position in forensics or broadcast journalism. I enjoy detailed activities, solving problems and public speaking.

What’s one of the things that you’ve learned from the job that’s helped you at home? I have learned that working hard as a team brings good outcomes for all involved.

What advice would you give someone just starting out here? How about advice for someone considering going into your field? My advice for a new employee within the Claims Department would be to get to know the team players involved in coordinating care for our claimants’; accept advice and knowledge of those with experience in the field; and maintain an honest and dependable work ethic. My advice for someone considering going into my field would be to consider that nursing requires a “giving” spirit and case management requires seeing the big picture as well as working in the details as you manage each unique case. The nursing field is rewarding, because it is truly in the giving of ourselves to others, that we receive a true blessing.

Tell us a little bit about your personal life. What do you enjoy doing when not in the office? How about family? Anything you’d like to share? Where did you grow up?