Brenda Caudill
RN CASE MANAGER
Versailles,KY
Summary
- An experienced RN and holds a BSN degree with extensive experience in case management, HEDIS quality assurance, insurance reviews, workers' compensation.
- Excellent experience in handling Disease Management programs for Commercial, Medicare Advantage, and Medicaid members with promotion of value-added services programs benefits.
- Expertise in performing quality chart review for quality issues for both Commercial, Medicare and Medicaid members and assisting with HEDIS quality measurement collection and reporting goal gaps.
- Experienced in Utilization Review, using InterQual and Milliman Care Guidelines/MCG for clinical reviews.
- Telephonic discharge planning, utilization review, telephonic guidance, chronic disease management, and wellness health education.
Compassionate Registered Nurse known for high productivity and efficient task completion. Skilled in patient assessment, and medication management. Excel at communication, teamwork, and empathy, ensuring optimal patient care and positive outcomes.
Overview
44
44
years of professional experience
1
1
Certification
Work History
RN
Self Employed Contractor
Versailles, KY
08.2017 - Current
- Contracted early childhood caregiver. Full time care for children 2 months to 5 years.
HEDIS REVIEWER-MEDICAID Abstraction contractor
LanceSoft
05.2016 - 01.2020
- Company Overview: www.Lancesoft.com
- Www.Lancesoft.com
RN-Nurse Care Management
CareSource Insurance
07.2016 - 09.2017
- Exchange commercial, Medicare, Medicaid chronic disease, and wellness case management for Kentucky members.
On-site RN
Anthem Inc
Lexington, KY
01.2015 - 10.2015
- For Baptist Hospital Lexington, KY and telephonic UM case reviewer-commercial/KY state business line acute hospitalization and discharge planning. Medical Management - Kentucky Employees Health Plan.
Medical Case Manager
Bradley Consulting & Management
03.2013 - 09.2014
- I conducted telephonic and Field Case management for injured workers across the United States with goal to return to work.
Nurse Case Manager
HUMANA Inc
Lexington, KY
08.2006 - 03.2013
- Telephonic Case Management with Humana Cares. Provided services to chronic disease members to enhance wellness and control of chronic disease management.
- Engaged members to follow up on physician directed quality measures.
- Referred members with barriers to Humana social services for assist in improving barriers to care.
- Followed up on inpatient and post hospitalization with members to reduce complications related to complex multiple chronic disease needs.
- Post discharge and on-site hospital reviews before discharge to coordination home needs.
- Job Goal was Steerage to Disease Management programs for Commercial & Medicare Advantage members with promotion of value-added services programs benefits.
- I exceeded department goals for disease management referrals using data and multiple resources to find appropriate candidates and coordinate discharge needs.
- I have used InterQual and MCG for clinical reviews effectively to determined medical necessity of level of care for acute and rehab needs.
- Performed quality chart review for quality issues for both Medicare and Commercial members and presented to Humana's Quality Management Committee.
- Assisted with HEDIS quality measurement collection and reporting goals.
Nurse Reviewer-Commercial Insurance
Bluegrass Family Health
Lexington, KY
01.2005 - 01.2006
- Telephonic and on-site care coordination for inpatient and outpatient members including discharge planning, utilization review, telephonic guidance, and health education.
- Central Baptist and University of Kentucky on-site review.
President and Senior Case Management
Triple J Benefits, Inc
Lexington, KY
01.1991 - 01.2005
- Federal Department of Labor workers compensation case management and clinical case reviews.
- Directed the Utilization and case management for inpatient and outpatient services and reviewed procedures for medical necessity and appropriateness of care.
- Conducted Field Case management and directed care for Federal employees in Kentucky and Ohio.
- On-site visits to facilities as needed to support patients/providers quality, and standards of practice with the primary goal of restore wellness/return to work.
Public Health Nurse
Lexington Fayette County Health Department
Lexington, KY
01.1981 - 01.1991
- I currently have an active Kentucky RN License for telephonic compact state reviews or telephonic follow up.
Education
BSN - Nursing
University of Virginia
Skills
- Program management
- Hospital Experience
- Motivational Interviewing
- Managed Care
- Quality Management
- Utilization Management
- Phone triage
- Workers' Compensation
- Documentation review
- Individual / Group Counseling
- Communication skills
- Medical Records
- Quality Assurance
- Acute care
- HEDIS
- Medicare
- Case Management
- Nursing
- MS Office
- Telephonic Nurse Care Management
- Disease Management
- InterQual and Milliman Care Guidelines/MCG
- Utilization Review
Certification
- Outstanding Utilization Management Nurse Certification
- Motivational Interviewing Program
- RN, 10/31/25, KY
Patents
Medical volunteer Lyons Club KY (#Community Screening and DM TEACHING)
Groups
Training In motivational interviewing
Personal Information
Authorized To Work: US
Timeline
RN
Self Employed Contractor
08.2017 - Current
RN-Nurse Care Management
CareSource Insurance
07.2016 - 09.2017
HEDIS REVIEWER-MEDICAID Abstraction contractor
LanceSoft
05.2016 - 01.2020
On-site RN
Anthem Inc
01.2015 - 10.2015
Medical Case Manager
Bradley Consulting & Management
03.2013 - 09.2014
Nurse Case Manager
HUMANA Inc
08.2006 - 03.2013
Nurse Reviewer-Commercial Insurance
Bluegrass Family Health
01.2005 - 01.2006
President and Senior Case Management
Triple J Benefits, Inc
01.1991 - 01.2005
Public Health Nurse
Lexington Fayette County Health Department
01.1981 - 01.1991
BSN - Nursing
University of Virginia
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