Summary
Overview
Work History
Education
Skills
Accomplishments
Timeline
Generic

Brandon Walters

Columbia,SC

Summary

Grievance & Appeals Coordinator with over 10 years of experience in enhancing healthcare services and resolving conflicts. Expertise in data analysis and process improvement, achieving increased efficiency in case resolution and reduced processing delays. Maintained high standards in document management and customer engagement, leading to improved member satisfaction. Skilled in navigating complex appeal processes and ensuring compliance with healthcare regulations, showcasing strong communication and problem-solving abilities.

Overview

10
10
years of professional experience

Work History

Grievance & Appeals Coordinator

Absolute Total Care
Columbia, SC
11.2019 - Current
  • Collect, evaluate, and document both verbal and written complaints, grievances, and appeals from members, and providers.
  • Draft response letters addressing member and provider complaints, grievances, and appeals.
  • Maintain records for individual appeals and grievances.
  • Assist in the administration of pay-for-performance programs, which include data entry, tracking, organizing, and conducting research.
  • Potentially coordinate the Grievance and Appeals Committee.
  • Support HEDIS production activities, including data entry, making calls to provider offices, and researching claims.
  • Ensure production efficiency by reviewing reports, allocating resources as needed, analyzing workflows, and suggesting improvements.
  • Maintain quality effectiveness by monitoring reports, and adjusting processes and procedures as required.
  • Gather and analyze operational data to understand the reasons behind calls, and identify areas for efficiency enhancement.
  • Engage in special projects aimed at personal or professional development, as well as achieving corporate and departmental objectives.
  • Analyze trends in claims processing issues, and identify work process solutions.
  • Document, track, and resolve all plan providers' disputes/claims projects.
  • Facilitate business initiatives by conducting data analysis, recognizing implementation obstacles, and performing user acceptance testing for new systems.
  • Conduct a thorough analysis on designated projects, propose viable business solutions, and aid in the implementation.

Lead Representative

Absolute Total Care
Columbia, SC
06.2018 - 11.2019
  • Attained an average customer satisfaction rating exceeding 95% over a three-year period.
  • Successfully addressed 93% of incoming customer inquiries and issues, escalating only the most intricate cases to the department manager.
  • Managed and responded to web inquiries from both members and providers within a 24-hour timeframe.
  • Gathered data and generated reports for ad hoc projects that were incorporated into company reports.
  • Performed quality call audits, offered recommendations for enhancing quality to management, and provided coaching and training for new employees.
  • Collaborated with various departments on cross-functional tasks and projects while upholding performance and quality standards in accordance with established call center metrics, including turnaround times.
  • Initiated change requests to address system configuration issues affecting claims processing and reviewed and tested the outcomes.
  • Investigated and resolved complex claims issues in partnership with health plan and corporate departments.

Customer Service Representative

Absolute Total Care
Columbia, SC
09.2015 - 06.2018
  • Responded to inquiries regarding member benefits, arranged for member materials, recorded member grievances, identified network providers or hospitals, and clarified any communications and programs sent to members.
  • Recognized as 'Employee of the Month' during my employment.
  • Highly articulate and proficient in engaging with individuals from diverse backgrounds and personalities.
  • Conducted monthly welcome call initiatives for new MMP members, provided information about the Healthy Connections Prime plan, documented and verified primary care providers, specialists, and medications, and educated members about their responsibilities concerning Care Managers.

Education

Bachelor of Science - Business Management

Claflin University
Orangeburg, SC
05.2015

Skills

  • Customer service
  • Microsoft Outlook
  • Microsoft Word
  • Microsoft Excel
  • Microsoft PowerPoint
  • Communication
  • Strategic planning
  • Active listening
  • Conflict resolution
  • Effective problem solver
  • Business management
  • Employee training
  • Data analysis
  • Machine learning
  • Claims processing
  • Grievance resolution
  • Strong analytical skills

Accomplishments

  • Member of Omega Psi Phi Fraternity Incorporated

Timeline

Grievance & Appeals Coordinator

Absolute Total Care
11.2019 - Current

Lead Representative

Absolute Total Care
06.2018 - 11.2019

Customer Service Representative

Absolute Total Care
09.2015 - 06.2018

Bachelor of Science - Business Management

Claflin University

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