Open to opportunities

Nikki Cleary

@nikkicleary

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Customer experience leader with 15+ years in healthcare engagement.

United States

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What I'm looking for

I am seeking a role that fosters collaboration and drives operational excellence in healthcare.

I am a seasoned Customer Experience Leader with over 15 years of experience driving growth through strategic relationships in the healthcare sector. My career has been marked by a commitment to enhancing provider engagement and operational efficiency, ensuring compliance with both state and federal regulations. At Delaware First Health, I lead a dedicated team focused on aligning our policies and strategic plans with the evolving needs of healthcare, while fostering cross-functional collaboration to optimize provider experiences.

Throughout my career, I have successfully managed complex projects and initiatives, translating data into actionable insights that empower executive leadership to make informed decisions. My roles have included managing engagement activities for Medicaid and Medicare lines of business, where I established cross-functional teams to resolve operational issues and improve performance metrics. My ability to mentor and develop staff has significantly improved employee retention and performance, contributing to a more effective organizational structure.

With a strong foundation in project management and a PMP certification, I am adept at leading large-scale initiatives that enhance CRM systems and streamline claims processing. I am passionate about driving improvements in healthcare delivery and am committed to being the voice of the provider, ensuring seamless service delivery and operational excellence.

Experience

Work history, roles, and key accomplishments

Current

Director, Provider Engagement

Current

Delaware First Health

Nov 2022 - Present (2 years 7 months)

Lead the Provider Engagement team, ensuring compliance with company policies and government regulations. Developed policies and strategic plans to align with future healthcare needs, driving cross-functional collaboration to enhance operational efficiency and provider experience.

Compliance Strategic Planning Cross Functional Collaboration Data Analysis Leadership Development Service Delivery Policy Development Healthcare Regulations

Manager, Business Engagement

AmeriHealth Caritas

Jun 2021 - Nov 2022 (1 year 5 months)

Managed engagement activities for Medicaid, Medicare, and Marketplace lines of business, ensuring compliance with regulatory contracts. Acted as the primary liaison between health plans and executives, driving improvements in performance and satisfaction through operational meetings.

Regulatory Compliance Performance Stakeholder Management Operational Meetings Key Performance Indicators

Business Solutions Consultant

Highmark

Sep 2020 - Jun 2021 (9 months)

Managed projects focused on Medicaid, CHIP, and LTSS platform enhancements. Led strategic initiatives to improve CRM and claims processing platforms, translating complex data into actionable insights for executive leadership.

Project Management CHIPS LTSS CRM Data Analysis Strategic Improvements Operational Visibility

Provider Account Liaison

Highmark

Jun 2018 - Sep 2020 (2 years 3 months)

Mentored new employees and managed relationships with health systems and ambulatory surgery centers. Led provider education and recruitment efforts, conducting root cause analysis on claims issues to improve payment accuracy.

Mentorship Claims Management Education Recruitment Root Cause Analysis Policy Awareness

Provider Relations Representative / Claims Analyst

United Healthcare

Aug 2015 - May 2016 (9 months)

Developed a state issue tracking mechanism and resolved complaints for Long Term Care and Medicaid lines of business. Collaborated with hospitals and healthcare systems to enhance provider relationships through education and claims analysis.

Issue Tracking Education Collaboration Contract Management

Complaint and Appeals Consultant

Aetna

Jan 2015 - Jun 2015 (5 months)

Managed high-volume Medicaid appeals and created appeal policies. Ensured workflows were updated with current regulations and led initiatives to improve the resolution process.

Appeals Policy Development Workflow Management Regulatory Compliance Communication Process Improvement Risk Management

Senior Consultant

Aetna

Oct 2011 - Jan 2015 (3 years 3 months)

Analyzed claims reimbursement issues and managed multi-million-dollar projects. Led cross-functional teams to implement system optimizations, enhancing claims adjudication accuracy.

Project Management Optimization Data Analysis Healthcare Regulations Claim Adjudication Risk Management Process Improvement Leadership

Education

Degrees, certifications, and relevant coursework

Wilmington University

Bachelor of Science, Business

Bachelor of Science degree, providing a strong foundation in various aspects of business and management, preparing graduates for leadership roles.

Project Management Institute

Certificate, Project Management

Project Management Professional (PMP) Certificate, demonstrating proficiency in project management principles and practices.

Western Governors University

Master of Science, Management & Leadership

Master of Science in Management & Leadership, focusing on developing leadership skills and understanding management principles to drive organizational success.