Nicole H.

Grievance and quality improvement review of cases, utilizing PQI systems such as Vivaldi and MHK to track trending quality issues. Worked with Medi-Cal, MediConnect, and Medicare quality cases.

Promoted to supervisor under Regulatory & Compliance department with 8 direct reports. Continues QI Nurse duties with daily appeals and grievance workload along with supervisory responsibilities. Successfully transitioned QI department to perform all job functions remotely as of March 2020 due to COVID-19 while ensuring compliance to turnaround times and maintaining optimal productivity. Perform oversight on QI workflows for Medical Group/IPA. Perform supervisor duties including annual performance reviews, corrective action plans, goal setting, timecard management, conflict management, maintaining schedules, employee training, and staff development. Developed and instituted key performance indicators for department. Develop trainings for medical management on Health Plan and federal regulatory standards (CMS, DMHC, and NCQA). Assist in managing all regulatory audits for the organization. Ensure timely, accurate, and complete submission of responses to regulatory auditors. Report audit results and findings to Leadership Team and stakeholders. Assist in designing and conducting audit readiness assessments. Conduct internal audits to determine gaps in compliance, opportunities for improvement, and assist in implementation of corrective actions. Collaborate with medical management leadership in responding to and coordinating actions for IAP/CAP. Develop regulatory audit trainings for medical management departments. Serve as a resource for providers/provider offices in navigating grievances and safety concerns. Collaborate with Claims, Risk Management, Provider Networking, Contracting, and Customer Service on practice improvement initiatives.

Served as liaison between health plans and medical group/IPA for member preservice appeals, claim appeals and grievances. Ensured all appeals/grievances were processed in compliance with health plan and CMS guidelines. Investigated and prepared responses to health plans regarding appeals and grievances. Worked collaboratively with internal departments to comply with health plan determinations. Identified trends and potential process improvements related to appeal/grievance data. Established and implemented member noncompliance, PCP Reassignment and Disenrollment letters process protocols in collaboration with Risk Management. Developed streamlined QI templates and workflows between IPA and medical group. Consolidated processes for appeals, grievances, Livanta (SNF and acute) appeals. Analyzed and reported data for quarterly reports at committee meetings. Responsible for investigating member grievances for Peer Review. Regularly collaborated with Medical Director leadership to effectively interpret data for Peer Review Committees, UM/QI Committees, and Credentialing Committees. Scheduled and performed internal Access Audits on contracted providers, specialists, and vendors. Developed and presented Regulatory & Compliance trainings. Designed satisfaction surveys for medical management using SurveyMonkey and interpreted survey data for medical management reports.

Established policies for Medical Records and Referral department in compliance with Federally Qualified Healthcare (FQHC) regulatory requirements. Performed nurse case manager functions such as identifying goals for high-risk patients while connecting patients to community resources. Assessed, planned, and implemented healthcare services for patients while monitoring their health status and timely delivery of care. Set SMART goals in collaboration with patients and their medical care team. Integrated evidence-based clinical guidelines when developing treatment plans. Presented patient cases as the team lead of the Multi-disciplinary Team (MDT). Identified and addressed high-risk socioeconomic barriers to patient care with MDT team. Performed Triage Nurse duties such as patient intake, triaging symptoms, medication reconciliation, and vaccine administration. Developed policies and procedures for Utilization Management and Medical Records departments. Collaborated with clinical department heads to achieve Patient-Centered Medical Home (PCMH) level 3 site designation. Experienced in HEDIS chart auditing. Performed medical record review. Performed patient eligibility as well as benefit verification for private and public insurers.

Managing medical assistants, their schedules, assignments, and direct patient care, manage back hall flow, perform eligibility screenings for patients, verify insurance and covered services, manage in-house laboratory, perform blood draw and handle lab specimen, work with labcorp/quest systems, troubleshoot EHR functions (MedAZ) to facilitate greater efficiency, perform inventory review of in-house dispensary, assist clinic in transition to full electronic records, report directly to Clinic Administrator

Held essential role in establishing new non-profit outpatient clinic in an underserved community. Instituted policies and procedures to comply with regulatory requirements as well as maintain patient/staff safety. Trained staff on patient care such as patient intake, phlebotomy, and EHR documentation. Interpreted and reported clinic operations data at monthly manager meetings with company stakeholders. Regularly assessed clinic processes for improvement and utilized LEAN strategies to remediate deficiencies. Organized volunteer events and recruited medical volunteers for mobile unit clinic community outreach for underserved populations. Participated in events and trainings with Coalition of Orange County Community Health Centers. Credentialed clinic providers with Medi-Cal programs such as Family Pact and VFC. Also credentialed providers with IPAs and private insurers. Performed clinical back office duties. Ensured effective operations by managing clinic inventory. Served as designated clinic representative at community events and presented grant applications at legislative city meetings. Conducted monthly Diabetes Education classes in English and Spanish to underserved communities.

Performed high volume wellness screenings hosted at various employer sites throughout Southern California. Wellness screenings included Biometrics, blood pressure, diabetes, and cholesterol. Provided disease education and resources to clients. Performed seasonal vaccine administration and point of care health screenings. Performed capillary phlebotomy and utilized Cholestech testing lab equipment.

• Organized and scheduled daily medications, assessed for therapeutic or adverse effect • Developed daily schedule for physical therapy, ROM exercises, and walking exercises • Assisted with breathing exercises and therapeutic pain therapy, hospice care, geriatric care • Utilized excellent communication and interpersonal skills, assisted with ADL's (dress/toilet/bed), and client transfer • Planned and prepared appropriate and nutritional meal plans per client, Experienced in 24 hour/noc shift client care