Caitlin Miller
Registered Nurse
Hanover,VA
Overview
11
11
years of professional experience
3
3
years of post-secondary education
Work History
Supervisor, Utilization Management
Sentara Health Plans
Richmond, VA
10.2021 - Current
- Promoted from Utilization Review Nurse to direct manager of a team of remote 20 direct reports comprised of RNs and LPNs
- Led our team of utilization review nurses through a merge of two health plans: Optima Health and Virginia Premier while promoting ongoing education and employee retention prior to and during the merge
- Responsible for maintaining NCQA, CMS, and DMAS compliance with authorizations reviewed by the team
- Responsible for training new staff
- Orchestrate weekly video team meetings with a scheduled agenda of topics
- Complete each direct report's performance evaluation
- Responsible for disciplinary actions, attendance, counseling, and performance improvement plans
- Complete monthly audits of approved and denied authorizations completed by each team member
- Milliman Care Guidelines (MCG) criteria knowledge
- InterQual criteria knowledge
- Mentor staff and provide ongoing education.
- Demonstrated respect, friendliness and willingness to help wherever needed.
- Demonstrated a high level of initiative and creativity while tackling difficult tasks.
- Identified issues, analyzed information and provided solutions to problems.
- Skilled at working independently and collaboratively in a team environment.
- Gained strong leadership skills by managing projects from start to finish.
- Participated in team projects, demonstrating an ability to work collaboratively and effectively.
- Applied effective time management techniques to meet tight deadlines.
- Demonstrated leadership skills in managing projects from concept to completion.
Utilization Review Nurse
Virginia Premier Health Plan
Richmond
07.2019 - 10.2021
- Reviewed Medicaid and Medicare authorization requests utilizing InterQual criteria for medical necessity to include outpatient therapies, durable medical equipment and specialty medical equipment, outpatient procedures, skilled nursing facilities, inpatient rehabilitation facilities, and long-term acute care hospitals
- Made referrals to case management for those members that need additional assistance
- Responsible for requesting clinical information for review
- Responsible for presenting, preparing, and submitting all recommendations for denial or approval for those cases that require review by the Medical Directors
- Responsible for communication and education to providers that request medical services and providing the approval or denial information
- Maintained all required documentation in the information system
- Managed assigned workload within the established performance standards
- Worked on special projects within the department.
Integrated Care Manager
Optima Health
Richmond
10.2018 - 07.2019
- Case management in a managed care organization servicing those enrolled in Medicaid throughout the state of Virginia by telephone
- Utilization management for private duty nursing services, home health authorization extensions, skilled nursing services, out-of-network approvals and letters of agreements, diabetic supplies, miscellaneous medical supplies, etc
- Coordination of care of complex medical patients to promote continuity of care
- Completed comprehensive health assessments of members
- Provided education to members regarding their health and medical conditions, as well as explanation of insurance benefits.
Registered Nurse, Oncology Infusion Nurse
Virginia Cancer Institute
Mechanicsville
07.2016 - 10.2018
- Performed venipuncture, accessed implanted ports, and maintained peripheral IV lines
- Modified treatment dosages by assessing patients, assessing labs, and consulting protocols
- Provided documentation in the electronic medical record for insurance authorization
- Competent in infusion administration to include chemotherapy, immunotherapy, iron products, electrolytes, and injections
- Triaged patients for health concerns, side effects of medications, lab results, and prioritize patient needs
- Assessed side effects of chemotherapy and other drugs and assessed adverse reactions to medications and administered emergency drugs if needed
- Provided patient education related to treatment and side effects
- Coordination of care and communication with other team members to give each patient comprehensive and holistic care
- Provided support and empathy for patients and family.
Registered Nurse, Neuroscience Telemetry Unit
Bon Secours St. Mary's Hospital
Richmond
04.2016 - 07.2016
- Managed the holistic, patient-centered care of 2-3 and up to 4 critical care patients daily, including every 4-hour neuro checks, wound care, and management of epilepsy, stroke, and brain injury patients
- Administered medications, assessed and evaluated patient outcomes, planned individualized care, education, and collaborated with the interdisciplinary team
- Adjusted to working every weekend and flexible hours.
Registered Nurse, Orthopedic Spine Center
Bon Secours St. Mary's Hospital
Richmond
01.2015 - 04.2016
- Managed the holistic care of 4-5 postoperative patients daily, including pain management and wound care, and collaborating with the interdisciplinary team
- Developed the plan of care and education for each patient
- Administered medications, assessed patients, planned individualized care for patients, evaluated patient outcomes, and provided discharge education
- Adjusted to working flexible hours and floating to other units of the hospital.
Patient Care Tech, Medical Oncology Unit
Bon Secours St. Mary's Hospital
Richmond
12.2013 - 01.2015
- Attended basic patient needs, including baths, vital signs, and blood sugar checks, and assisted nurses with any patient care.
Extern Nurse, Orthopedic Spine Center
Bon Secours St. Mary's Hospital
Richmond
06.2014 - 07.2014
- Worked as an extern nurse under the supervision of a registered nurse for the eight-week program offered to nursing students
- Provided culturally sensitive and family centered care
- Performed skills such as starting IVs, drawing blood, inserting and removing Foley catheters, removing Hemovacs, patient and discharge teaching, and wound care.
Summary
Experienced Supervisor leads team members to complete jobs on-time. Assigns tasks, trains employees, and implements company procedures. Excellent communication and listening skills. Provides leadership and vision, driving teams to meet goals.
Experienced in Medicaid Managed Care utilization management and case management.
Education
Bachelor of Science - Nursing
Bon Secours Memorial College of Nursing
Richmond, VA 08.2011 - 12.2014
Skills
- Staff Management
- Data Analytics
- Process Improvement
- Training and mentoring
- Process Monitoring and Improvement
- Staff Development
- Processes and procedures
Timeline
Supervisor, Utilization Management
Sentara Health Plans
10.2021 - Current
Utilization Review Nurse
Virginia Premier Health Plan
07.2019 - 10.2021
Integrated Care Manager
Optima Health
10.2018 - 07.2019
Registered Nurse, Oncology Infusion Nurse
Virginia Cancer Institute
07.2016 - 10.2018
Registered Nurse, Neuroscience Telemetry Unit
Bon Secours St. Mary's Hospital
04.2016 - 07.2016
Registered Nurse, Orthopedic Spine Center
Bon Secours St. Mary's Hospital
01.2015 - 04.2016
Extern Nurse, Orthopedic Spine Center
Bon Secours St. Mary's Hospital
06.2014 - 07.2014
Patient Care Tech, Medical Oncology Unit
Bon Secours St. Mary's Hospital
12.2013 - 01.2015
Bachelor of Science - Nursing
Bon Secours Memorial College of Nursing
08.2011 - 12.2014
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