Nicole Reed
Quality Nurse at VIVA HEALTH- Claim this Profile
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Bio
Credentials
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Lean Six Sigma Green Belt (ICGB)
Institute of Industrial and Systems EngineersAug, 2019- Oct, 2024
Experience
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VIVA HEALTH
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Switzerland
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Health and Human Services
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Quality Nurse
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Sep 2020 - Present
Abided by all federal and state regulations, including CMS regulations and HIPAA, while managing medical records and claims information for HEDIS chart abstraction. Organized member outreach, facilitated interventions, and effectively engaged physicians, their office staff, members, and providers to elevate member outcomes. Fostered collaboration and problem-solving at interdepartmental meetings and workgroups as QI liaison. Promoted wellbeing of patients by guiding expert recommendations and implementing care plans. ● Championed development and execution of performance improvement initiatives as well as scrutinized and deciphered quality performance data against benchmarks. ● Reached out to over 90% of assigned members successfully. ● Achieved five-star ratings for two consecutive years. ● Led HEDIS abstraction accuracy rate of 98.7%. Show less
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Optum
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United States
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Hospitals and Health Care
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300 - 400 Employee
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Pre Service Review Nurse
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Nov 2019 - Sep 2020
Examined requests from providers to ensure medical appropriateness of inpatient and outpatient services. Utilized evidence-based medical policies, benefit plan documents, and nationally recognized clinical guidelines to conduct preservice clinical coverage reviews. Acquired comprehensive knowledge of health appropriateness criteria, benefit plan documents, and evidence-based medical policy. ● Accomplished success rate of 97% in determining medical appropriateness. Examined requests from providers to ensure medical appropriateness of inpatient and outpatient services. Utilized evidence-based medical policies, benefit plan documents, and nationally recognized clinical guidelines to conduct preservice clinical coverage reviews. Acquired comprehensive knowledge of health appropriateness criteria, benefit plan documents, and evidence-based medical policy. ● Accomplished success rate of 97% in determining medical appropriateness.
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NaphCare, Inc.
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United States
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Hospitals and Health Care
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700 & Above Employee
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Utilization Review Nurse
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2015 - Sep 2019
Assessed and validated medical necessity of outpatient, inpatient, and specified imaging testing according to Milliman policies. Implemented policies and procedures for utilization review. Consolidated clinical information to evaluate and expedite care needs. Assembled diagnosis codes and CPT codes from providers, and reviewed patient records to determine medical necessity.● Directed provider requests to Medical Director when services failed to meet recognized criteria and actively participated in Utilization Management.● Effectively reduced hospital readmission rates by 92%, resulting in cost savings.● Governed concurrent review to decrease hospital admission rates by 90%.● Lowered unnecessary testing by over 89% by identifying alternative treatments and diagnostics. Show less
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Director of Community Medical Services
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Jun 2007 - 2015
Oversaw team of over 25 members across Medical Records, Consolidation, and Scheduling departments. Facilitated case management for hospitalized inmates, led workflow processes for upcoming jail startups. Administered Federal and Jail Operations workflow issues, workload, and site assignments. Implemented utilization management enhancements within EMR, trained sites and corporate personnel on process. Reviewed productivity reports from leads and managers, making necessary adjustments for discipline, conduct, time off, and expectations. Developed departmental goals and objectives, communicating, and implementing responsibilities' expectations.● Successfully reduced scheduling turnaround time to four hours expedited, 24 hours urgent, and 48 hours routine at 98%, reducing wait times for scheduled appointments.● Accomplished 90-day success onboarding new facilities.● Served as primary point of contact with jail sites as well as liaison among Claims department, jails, internal staff, UM nurses, and healthcare providers. Show less
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Education
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2021 - 2023
University of Alabama at Birmingham
Master's degree, Healthcare administration -
2018 - 2020
University of Alabama at Birmingham
Master's degree, Healthcare Quality and Safety -
2004 - 2006
University of Alabama at Birmingham
Bachelor of Science (BS), Health/Health Care Administration/Management
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