Nikki Nicole

Patient-focused Care Navigator with 8+ years at UnitedHealthcare coordinating care for 100+ Medicare/Medicaid members monthly to close care gaps, improve adherence, and reduce avoidable ED use. Expert in needs assessments, post-discharge transitions, benefits navigation, and interdisciplinary collaboration; consistently meets or exceeds outreach and quality-improvement targets. Former medical reviewer with 13+ years in utilization management and clinical review, bringing strong EHR and medical billing expertise to optimize documentation, care coordination, and member outcomes.

Care Navigator - United Healthcare - New Orleans

(2018-09 - 2026-04)

• Managed care coordination for 100+ Medicare/Medicaid members monthly: performed comprehensive needs assessments, developed individualized care plans, and coordinated services across primary care, specialists, behavioral health, and community providers.
• Performed inbound/outbound outreach and triage for referrals and high-risk members, facilitating timely access to care and appropriate level-of-service, including scheduling appointments and arranging transportation.
• Executed post-discharge follow-up and transitional care interventions to ensure medication reconciliation, home support, and follow-up appointments, helping prevent care gaps and unnecessary ED utilization.
• Collaborated with interdisciplinary teams (case managers, social workers, PCPs, behavioral health specialists) to resolve barriers to care—housing, social determinants, and benefits navigation—and escalate complex cases as needed.
• Maintained accurate clinical documentation in EHR/CRM systems, tracked member outcomes and care-gap closures, and met/exceeded outreach and quality-improvement performance targets.
• Educated members and caregivers on care plans, medication management, and community resources to improve engagement and self-management.

Medical Reviewer - National Medical Reviewers

(2005-02 - 2018-08)

• Conducted thorough clinical reviews of medical records to determine medical necessity and adherence to payer guidelines, applying evidence-based criteria and utilization management protocols.
• Performed peer review and case adjudication, authored clear clinical rationale and determination letters, and communicated findings to providers and internal stakeholders.
• Managed a high-volume caseload while meeting turnaround-time and quality benchmarks; identified documentation gaps and recommended corrective actions to reduce billing and clinical risk.
• Collaborated with utilization management, quality assurance, and appeals teams to resolve complex cases and support process improvements; trained and mentored new reviewers on clinical standards and review workflows.

Medical Billing and coding - Bryman College (2004-01 - 2024-12)