Colleen Miller RN, BSN
Cranberry Township,PA
Summary
Dynamic Utilization Management Nurse with over 33 years of comprehensive nursing experience, including 15 years in utilization management and managed care. Expertise in developing and implementing determinations for inpatient, post-acute, prior authorization, and retrospective services to ensure optimal patient outcomes. Strong communicator and collaborator, skilled in engaging with healthcare organizations to secure essential medical information and uphold appropriate levels of care. Proven ability to thrive independently in remote environments for over a decade, demonstrating adaptability and self-motivation.
Overview
33
33
years of professional experience
Work History
Utilization Management Registered Nurse
Highmark Health, Inc
04.2024 - Current
- Process preauthorization requests for inpatient, outpatient, diagnostic, and therapy services, ensuring timely and accurate determinations.
- Review medical necessity criteria and supporting documentation, rendering decisions based on MCG Milliman Care Guidelines, Medicare regulations, and Highmark policies.
- Collaborate with senior care managers and medical directors to review complex cases
- Communicate approvals and denials effectively to providers
Utilization Management Registered Nurse
UPMC Health Plan
10.2010 - 01.2024
- Conduct acute and post-acute initial and continued stay reviews using InterQual criteria, ensuring appropriate levels of care.
- Apply Medicare and Medicaid policies and regulations while adhering to quality, timeliness, and productivity standards.
- Collaborate with medical directors on complex cases
Clinical Coordinator
UPMC After Hours Clinic
01.2010 - 10.2010
- Supervised and managed daily activities of a clinical team, including physicians, nurses, and support staff.
Field-Based Nurse Chart Reviewer
Med-Assurant
06.2008 - 10.2010
- Performed medical record abstraction in support of annual Healthcare Effectiveness Data and Information Set (HEDIS) data collection.
- Applied knowledge of NCQA HEDIS abstracting guidelines and accessed medical records in both electronic and paper formats.
Professional Staff Nurse, Neurological Unit
UPMC Shadyside Hospital
03.2007 - 01.2010
- Performed neurological and cardiac assessments, including cardiac monitoring, in direct patient care.
- Collaborated with physicians to rapidly assess patients and deliver appropriate treatment while managing rapidly changing conditions.
Rehabilitation Registered Charge Nurse
UPMC Rehabilitation Hospital
03.1997 - 07.2003
- Provided care for patients with traumatic spinal cord injuries, brain injuries, and orthopedic trauma.
Physician Credentialing
Pennsylvania Select
01.2001 - 12.2002
- Conducted physician credentialing for the Physician Hospital Organization associated with a network of community hospitals in Pennsylvania.
Staff Nurse, Neurological Unit
Shadyside Hospital
09.1992 - 03.1997
- Performed neurological and cardiac assessments, including cardiac monitoring, in direct patient care.
Education
Bachelor of Science - Nursing
Waynesburg University
Waynesburg, PA05.2008
Associate of Science - Nurse
Community College of Allegheny County
Pittsburgh, PA10.1992
High School Diploma - undefined
South Side Catholic
Pittsburgh, PA05.1985
Skills
- Skilled in Microsoft Office tools
- Excel spreadsheet management
- Electronic health record expertise
- Skilled in managing workflows
- Strong performance in high-stress situations
- Comprehension of healthcare policy frameworks
- Experienced in applying InterQual criteria and Milliman Care Guidelines (MCG)
- Understanding of NCQA guidelines
Timeline
Utilization Management Registered Nurse
Highmark Health, Inc
04.2024 - Current
Utilization Management Registered Nurse
UPMC Health Plan
10.2010 - 01.2024
Clinical Coordinator
UPMC After Hours Clinic
01.2010 - 10.2010
Field-Based Nurse Chart Reviewer
Med-Assurant
06.2008 - 10.2010
Professional Staff Nurse, Neurological Unit
UPMC Shadyside Hospital
03.2007 - 01.2010
Physician Credentialing
Pennsylvania Select
01.2001 - 12.2002
Rehabilitation Registered Charge Nurse
UPMC Rehabilitation Hospital
03.1997 - 07.2003
Staff Nurse, Neurological Unit
Shadyside Hospital
09.1992 - 03.1997
Associate of Science - Nurse
Community College of Allegheny County
High School Diploma - undefined
South Side Catholic
Bachelor of Science - Nursing
Waynesburg University