Nicole Gurley
Brooklyn,NY
Summary
Drawing on 17 years in the healthcare industry, I've developed into a dedicated healthcare professional. Driven by a passion for assisting others and a commitment to personal growth, I've consistently thrived in various roles. Currently, as a vendor relationship manager, my rapid advancements highlight my ability to excel in my role, exceeding company goals and tackling challenges from a senior leadership perspective.
Overview
12
12
years of professional experience
Work History
Vendor Relationship Manager,
EmblemHealth
06.2022 - Current
- Oversee all activities associated with payment integrity vendor contracts, including development, optimization, and negotiation while ensuring compliance with organizational practices and regulatory procedures
- Update job knowledge and understanding by participating in policy meetings, quarterly business reviews, and reimbursement policy/steering committees
- Orchestrated the development and implementation of new programs, contract performance standards, and associated penalties
- Strategically managed vendor relations, key projects, root cause analysis, and pre-contractual and implementation activities
- Reviewed opportunities as well as led business case development, savings opportunity analysis, and creation of related projects
- Recognized for managing business aspects of all EPMO and IT projects; deploy top-tier project management skills to steer and deliver projects/assignments within timely, budgetary, and scope constraints
- Provided subject matter expertise throughout all contract aspects to ensure consistency, optimal contract management, and successful outcomes; leveraged exceptional communication and interpersonal skills to negotiate contracts
- Drafted and presented weekly and monthly invoice reports to assist executive management with decision-making; conducted reviews and reconciliations prior to submission to identify and address inconsistencies or errors
- Enhanced reporting accuracy and achieved a significant increase in savings by identifying system and process enhancements
- Promptly responded to all issues, concerns, and inquiries related to vendor contracts in a highly professional and courteous manner, while serving as a key point of communication and collaborating with internal business units.
HARP Behavioral Health Liaison,
Centene Corporation
07.2018 - 06.2022
- Streamline administrative workflow for optimal efficiency by coordinating services related to HARP members, including scheduling appointments, arranging transportation, securing medical providers, obtaining health records, documenting authorization, placing appointment reminders and follow-up calls to ensure convenient healthcare access
- Delivered operational support to HARP care managers dealing with high acuity clinical cases
- Act as a liaison between providers and care teams, assuring timely access to clinical staff for triage and resolution of clinical problems
- Participated in QARR/HEDIS initiatives to maximize clinical performance ultimately exceeding State quality standards
- Networked with providers and health homes to facilitate referrals and follow through on services based on the care plan
- Improved data accuracy in information systems/electronic records, process prospective utilization management requests
- Researched NYS Office of the Professionals to ensure all members received high–quality, specialized healthcare amenities
- Achieved 100% client satisfaction by resolving complaints and clarifying queries regarding billing and health coverage
- Proficient in using computer systems to input orders, authorizations, access records, and retrieved pertinent information.
Health Advisor,
NYC Health + Hospitals
05.2020 - 07.2021
- Effectively communicated and demonstrated the system’s acknowledgment and awareness of diverse health-related needs and concerns to patient, family members, caregivers, staff, and the community
- Provided follow-up instructions to cases and to contacts related to isolation or quarantine, symptom monitoring, and assessed the need for medical care and supportive services for the individual and/or household or close contacts
- Collected information from case interview/contact gathering and recorded them into the data system following standard operating procedures
- Conducted telephone calls with persons diagnosed with COVID-19 to complete case interviews, elicited and traced contacts exposed to COVID-19, communicating with cases and contacts in a professional and empathetic manner
- Followed approved scripts and protocols, provided people with approved information about isolation and quarantine procedures, and if appropriate, referred them for testing while protecting and maintaining the individuals’ privacy and confidentiality
- Managed the assigned caseload while ensuring prompt and accurate data entry and follow-ups with cases and/or contacts and case escalation to the supervisor, as appropriate, recognizing, documenting, and alerting the supervisor of any trends in the customer calls
- Checked the records for accuracy of information and for conformity with the company’s established policies and procedures.
Child Protective Specialist,
Administration for Children's Services
11.2017 - 07.2018
- Investigated alleged abuse, neglect, and abandonment of children by conducting field visits, analyzing abusive conditions, and initiating prompt action to ensure children’s well-being and safety in accordance with state-mandated timeframes
- Collaborated with the staff and service providers to assess the safety and identify interventions to reduce risks to children
- Interviewed family members and engaged in a strength-based approach to evaluate their individual and collective needs
- Removed children into protective custody or foster care, during situations involving children in imminent danger and threat
- Maintained comprehensive case records, filed petitions, and testified in family court as well as attended legal proceedings
- Coordinated service referrals, assisted family members to navigate government agencies and access entitlement benefits.
Case Manager (temporary),
Federation of Organizations
03.2017 - 10.2017
- Provided crisis intervention, guidance, and health promotion to mental health consumers
- Advocated for full inclusion of individuals with chronic conditions in the community by linking necessary services and working with the service provider
- Designed personalized service plans outlining client objectives and case manager interventions to meet consumer’s needs
- Linked behavioral, medical, residential, social, financial, vocational resources, and collateral contacts with clinical treatment
- Monitored cases and crafted progress reports, followed up with treatment programs and educated on preventive medicine
- Directed the training of team members on best practice workflows, relevant legislation, and internal policies expeditiously
- Developed congenial client relations and cooperated with the medical team throughout the case management process.
Managed Long Term Care Coordinator,
WellCare Health Plans Inc.
05.2012 - 10.2015
- Accountable for the full patient care cycle including corresponding with contracted providers, vendors, WellCare contacts, and members representatives to ensure the provision of equitable, client–centered care at an affordable cost
- Delivered bespoke technical and administrative support to clinical and behavioral staff in addition to supporting nursing tasks such as admittance and discharge preparations, requests for clinical information, and creation of authorization
- Interfaced with teams across multiple departments to enhance the quality of services, exceeding the client’s expectations
- Actively assisted WellCare members with onboard knowledge of programs and reintroduction to assigned case manager
- Finalized authorizations in a timely fashion to ensure that all members were treated well and provided exceptional care
- Conducted quality reviews on each plan to validate ICD-10 codes and detail review of Medicaid and MCPs utilizing EPACES.
Education
Master of Arts - Health Care Administration
Utica College of Syracuse University, NY
01.2020
Bachelor of Arts - Psychology
Brooklyn College, NY
01.2014
Associate of Science - Early Childhood Education
Kingsborough Community College, NY
01.2011
Skills
- Healthcare Administration
- Managed Care (PPO, HMO)
- Medicare / Medicaid
- Patient Scheduling
- Coordinated Behavioral Care
- Electronic Health Records
- Resource Optimization
- Insurance Authorization
- Team Building and Leadership
- Project Management
- Client Service Excellence
- HIPAA Compliance
- Contracting and Invoicing
- Vendor Management
- Budgeting and Finance
- Provider Relations
- Cost Control
Timeline
Vendor Relationship Manager,
EmblemHealth
06.2022 - Current
Health Advisor,
NYC Health + Hospitals
05.2020 - 07.2021
HARP Behavioral Health Liaison,
Centene Corporation
07.2018 - 06.2022
Child Protective Specialist,
Administration for Children's Services
11.2017 - 07.2018
Case Manager (temporary),
Federation of Organizations
03.2017 - 10.2017
Managed Long Term Care Coordinator,
WellCare Health Plans Inc.
05.2012 - 10.2015
Master of Arts - Health Care Administration
Utica College of Syracuse University, NY
Bachelor of Arts - Psychology
Brooklyn College, NY
Associate of Science - Early Childhood Education
Kingsborough Community College, NY
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