Joshua Miles
Temecula,CA
Summary
Professionally trained Registered Nurse, licensed in CA, NV, NY, with proven experience in Utilization Management, Case Management, and Acute Care. My professional training and job experiences have afforded me the skills and knowledge to work every day to better utilize resources and improve quality in the healthcare delivered.
Overview
9
9
years of professional experience
1
1
Certification
Work History
Utilization Management, RN II
Anthem Blue Cross Blue Shield
06.2018 - Current
- Prior Authorization reviews for inpatient and outpatient surgeries, procedures, and medications.
- Concurrent and Retrospective reviews for Acute Care, LTAC, ARU, SNF, and Comprehensive Rehabilitation.
- Utilize and maintain EMR access for enhanced review times.
- Consult with Medical Directors to ensure medically appropriate, cost effective care throughout the medical management process.
- Collaborate with Providers to ensure member access to medically necessary services and procedures.
- Perform Discharge Planning and work with Case Management regarding cases with high cost potential.
Quality Assurance, RN
Memorial Care
02.2017 - 06.2018
- Ensure medically appropriate, cost effective care by individual case analysis of medical necessity and appropriateness of services for all Medicare patients.
- Apply clinical knowledge to guarantee ICD-10 coded diagnoses are accurate and supported by clinical evidence and documentation.
- Clinical Training Coordinator for OASIS, CMS Guidelines, and Agency Policies and Procedures.
- Review all Physician Orders and Therapist Evaluations
- Audit charts for compliance with CMS regulations and Agency Policies.
Case Manager, RN
Memorial Care Home Health
09.2016 - 02.2017
- Develop patient care plans and coordinate care among an interdisciplinary team of Providers.
- Manage LPN/LVN's and oversee the implementation of Physical, Occupational and Speech Therapy.
- Evaluate treatment plans against individual goals and healthcare standards.
- Educate on disease processes, medication management, home safety, community resources, and patient advocacy.
- Discharge planning and/or referrals to higher levels of care.
Surgical ICU Registered Nurse II
University of Rochester - Strong Memorial Hospital
03.2015 - 08.2016
- Critical thinking to respond to life-threatening situations using nursing standards and protocols for treatment.
- Quickly adapt to constantly changing conditions within a high pressure environment for successful patient outcomes.
- Assist in emergent bedside procedures including invasive line placements, intubations, bronchoscopies, and hemodialysis.
- Maintain high-level interpersonal skills to effectively communicate among a diverse interdisciplinary care team.
- Prioritize patient care according to acuity, procedures, and interventions.
- Provide education and support to patients and families.
- Charge Nurse and Preceptor
Education
Associate of Science - Nursing
State University of New York - Monroe Community College
Rochester, NY2014
Bachelor of Science - Business Administration and Management
State University of New York - College At Brockport
Brockport, NY2007
Skills
- RN incensed in CA, NV, NY
- Prior Authorization / Precertification
- Concurrent & Retrospective Review
- Outpatient & Inpatient Review
- Milliman (MCG), Interqual, AIM
- EMR
- Case Management
- Discharge Planning
- Microsoft Teams, Outlook, Office Products
- Prioritizing & Managing Deadlines
- Strong interpersonal skills
- High level of autonomy
Certification
- Registered Nurse - State of California - License #95098143
- Registered Nurse - State of Nevada - License #811696
- Registered Nurse - State of New York - License #696501
- BLS Certified by the American Heart Association
Timeline
Utilization Management, RN II
Anthem Blue Cross Blue Shield
06.2018 - Current
Quality Assurance, RN
Memorial Care
02.2017 - 06.2018
Case Manager, RN
Memorial Care Home Health
09.2016 - 02.2017
Surgical ICU Registered Nurse II
University of Rochester - Strong Memorial Hospital
03.2015 - 08.2016
Associate of Science - Nursing
State University of New York - Monroe Community College
Bachelor of Science - Business Administration and Management
State University of New York - College At Brockport
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