Nicole Creech
Zebulon,NC
Summary
Clinical Review Nurse with expertise in Medicaid appeals, medical necessity determinations, and regulatory compliance with State, Federal and NCQA standards. Experienced in analyzing complex medical records, preparing case reviews for Medical Directors, and ensuring timely appeal resolution. Proven ability to mentor new clinical staff, manage case volumes, and collaborate with leadership to improve appeals processes and operational efficiency.
Overview
11
11
years of professional experience
1
1
Certification
Work History
Clinical Review Clinician, Appeals
Centene
06.2024 - Current
- Perform comprehensive clinical reviews of medical records to determine medical necessity for appealed services using clinical data, evidence-based criteria, and applicable State, Federal, and National Committee for Quality Assurance (NCQA) standards.
- Partner with leadership to identify trends and recommend process improvements within the appeals workflow to enhance efficiency and prevent recurring issues.
- Assign daily appeal case volumes to clinical staff to ensure balanced workloads and timely case processing.
- Precept and mentor newly hired nurses, providing onboarding support, training in systems and workflows, and guidance on regulatory policies and clinical review processes.
- Prepare detailed case summaries and clinical analyses for Medical Directors, outlining the basis of the appeal and relevant medical necessity criteria.
- Ensure timely review, processing, and resolution of appeals in compliance with regulatory and NCQA timelines and standards.
- Communicate effectively with members, providers, facilities, and internal departments regarding appeal status, escalations, and clinical determinations.
- Maintain strict adherence to all organizational policies, regulatory requirements, and compliance standards.
Clinical Nurse II, Neuroscience Stepdown
WakeMed Health and Hospitals
02.2022 - 05.2024
- Provide direct patient care in a fast-paced Neuroscience Stepdown unit, specializing in the care of patients with neurological disorders and injuries.
- Recognized for compassionate patient care and professionalism through multiple DAISY Award nominations.
- Collaborate with interdisciplinary teams of physicians, therapists, and case managers to develop and implement individualized care plans, while focusing on utilization management.
- Educate patients and their families on their conditions, treatment plans, and self-care strategies to promote patient empowerment and facilitate successful transitions to home care.
- Administer medications, track dosages, monitor vital signs and telemetry, and manage drains and tubes as per established protocols and best practice guidelines.
- Facilitate patient admission, transfer, and discharge processes.
- Proficient in using EPIC to document patient conditions.
- Advise, coach, and mentor experienced and new graduate nurses on standards of care, crisis management and appropriate nursing interventions.
Healthy Kids Division Manager
Down East Partnership for Children
06.2019 - 05.2020
- Coordinated program development and community planning around food access, safe places for physical activity, and innovations in medical practices.
- Managed a team comprised of 9 personnel, provided coaching and mentorship, conducted performance evaluations, and established inclusive work cultures.
- Staffed and facilitated collaborative meetings and planning sessions with Board Officials, Principals, Hospital Directors, Health Department Directors, Social Workers, Town Planners, etc.
- Supported the planning and implementation of new funding streams.
- Managed five budgets for the Research and Development Team.
Regional Grants Lead Coordinator
Johnston County Public Health Department
08.2015 - 05.2019
- Created and managed a team of partners across eight counties to meet health program objectives in areas such as diabetes, obesity, heart disease, physical activity, food access, and stroke prevention.
- Analyzed needs in the community and created or enhanced programs and policies in accordance with those needs.
- Conducted data collection measures and program evaluation.
- Managed a $100K budget with expenditures spread across eight counties.
Education
Bachelor of Science - Nursing
University of North Carolina at Chapel Hill
08-2021
Bachelor of Science - Public Health Studies
University of North Carolina at Wilmington
07-2015
Skills
- Process Improvement & Workflow Optimization
- Clinical Staff Mentorship & Precepting
- Quality Assurance & Case Accuracy
- Medical Necessity Review
- Clinical Criteria Interpretation
- Medical Record Analysis
- Interdisciplinary Collaboration
- Case Volume Management and Assignment
Certification
- Registered Nurse NCBON August 2021
Timeline
Clinical Review Clinician, Appeals
Centene
06.2024 - Current
Clinical Nurse II, Neuroscience Stepdown
WakeMed Health and Hospitals
02.2022 - 05.2024
Healthy Kids Division Manager
Down East Partnership for Children
06.2019 - 05.2020
Regional Grants Lead Coordinator
Johnston County Public Health Department
08.2015 - 05.2019
Bachelor of Science - Public Health Studies
University of North Carolina at Wilmington
Bachelor of Science - Nursing
University of North Carolina at Chapel Hill