BRIANNA JOHNSTON

Remote

• Review and investigate complex member and provider grievances and appeals, ensuring compliance with regulatory requirements, health plan policies, and internal guidelines.
• Analyze claims, authorization records, medical documentation, and benefit information to determine eligibility, coverage, and appropriate case resolution.
• Conduct comprehensive investigations by collaborating with internal departments, delegated entities, providers, and external stakeholders to gather supporting documentation and resolve issues.
• Prepared detailed case summaries and recommendations for medical and administrative review, ensuring accurate documentation supported final determinations.
• Draft professional written correspondence, including acknowledgment letters and case determinations, while maintaining compliance with regulatory and organizational standards.
• Communicate directly with members, authorized representatives, providers, and internal teams to obtain additional information, clarify concerns, and provide case updates.
• Researched case files to identify discrepancies, documentation deficiencies, and compliance issues, coordinating with cross-functional teams to ensure timely resolutions.
• Monitor and manage a high-volume caseload, consistently meeting regulatory turnaround times, internal service-level agreements, and productivity goals.
• Created and maintained detailed case documentation, service requests, and tracking records to support reporting, auditing, quality assurance, and regulatory compliance.
• Partner with clinical, operational, and administrative teams to improve workflow efficiency, ensure accurate case processing, and deliver high-quality member service.

Remote

• Coordinated client accounts and supported large-scale retail marketing initiatives across multiple locations.
• Coordinated account planning and project management to meet client objectives and timelines.
• Oversaw project coordination by tracking deliverables and maintaining accurate data for successful implementation of client programs.
• Managed account reporting by preparing standard and ad hoc reports on account status and project progress.
• Coordinated scheduling and managed a team of 90+ Brand Ambassadors across the Northeast region, ensuring appropriate staffing, operational efficiency, and successful event execution.
• Partnered with cross-functional teams to maintain high levels of client satisfaction while improving workflow efficiency and operational performance.
• Resolved operational issues by researching discrepancies, coordinating approvals, expediting customer requests, and collaborating with internal departments to achieve timely resolutions.
• Developed comprehensive event manuals, operational guides, and supporting documentation to communicate expectations and streamline execution.
• Drafted client agreements, contracts, and other business documentation to support new and existing partnerships.

Remote

• Managed high-volume workload of 60+ inbound and outbound calls daily, consistently meeting productivity and quality standards.
• Educated new patients on program services and successfully enrolled eligible patients or coordinated appointments.
• Re-engaged hard-to-reach patients by researching updated contact information and coordinating targeted follow-up outreach.
• Collected, verified, and documented accurate patient information while maintaining complete HIPAA compliance.
• Escalated clinical concerns to licensed Registered Nurses to ensure timely patient care.
• Performed administrative and process-related tasks to support patient engagement initiatives and improve operational efficiency.
• Tested new programs and workflows, providing actionable feedback to enhance processes and improve patient experience.
• Served as a Team Lead/Trainer by onboarding and mentoring new hires and collaborating across multiple programs.