Donice Smith
Bowie,MD
Summary
Case Management & Healthcare Operations Specialist | Appeals & Grievances | Prior Authorization | Customer Success Administration | Tech Support
Overview
26
26
years of professional experience
Work History
REMOTE SR CLIENT SERVICES REPRESENTATIVE
Telecommunications Development Corp
Washington, DC
11.2025 - Current
- Served as the primary point of contact for members, providers, brokers, and employer groups, resolving complex inquiries related to benefits, eligibility, claims, enrollment, billing, prior authorizations, appeals, and grievances.
- Managed high-volume casework and case management activities, investigating coverage determinations, authorization requests, and escalated issues while ensuring compliance with HIPAA, CMS, NCQA, regulatory requirements, and service-level agreements (SLAs).
- Collaborated with Claims, Enrollment, Finance, Care Management, Utilization Management, Provider Services, and Sales teams to resolve complex cases, improve member outcomes, and support timely access to care.
- Provided technical and customer support through troubleshooting, root-cause analysis, and issue resolution; utilized Salesforce, PowerBuilder, and Help Scout to manage cases, document interactions, track resolutions, and identify process improvement opportunities.
REMOTE SENIOR CUSTOMER SERVICE REPRESENTATIVE
United Healthcare, UHG
10.2022 - 08.2025
- Increased member satisfaction and retention by 25%+ through proactive outreach, benefits education, member advocacy, personalized support, and case management for Medicare and Medicaid D-SNP populations.
- Managed complex case management activities, investigating and resolving appeals, grievances, complaints, coverage determinations, and escalated member/provider issues involving claims, prior authorizations, eligibility, billing, and provider access while ensuring compliance with CMS, HIPAA, and NCQA standards.
- Conducted comprehensive case reviews by analyzing claims, eligibility records, authorization requests, provider documentation, and benefit plans to support accurate healthcare determinations, care coordination, and timely access to services.
- Leveraged Salesforce and healthcare systems to manage case activity, coordinate cross-functional resolutions, connect members with healthcare and community resources, improve case resolution efficiency by 30%, and mentor new team members on compliance and customer service best practices.
RADIOLOGY PATIENT ACCESS REPRESENTATIVE
MedStar Washington Hospital Center
Washington, D.C.
12.2018 - 08.2020
- Improved patient scheduling accuracy by 35% through precise coordination of MRI, CT, ultrasound, and interventional procedures, ensuring correct modality, provider, and pre-procedure requirements.
- Enhanced billing and insurance compliance by verifying coverage, obtaining prior authorizations, and correcting ICD-10 coding errors, directly reducing claim denials and improving reimbursement turnaround times.
- Strengthened patient satisfaction and department efficiency by reducing average wait times and supporting same-day access initiatives that increased throughput without compromising care quality.
- Collaborated cross-functionally with radiologists, technologists, and nursing staff to prioritize urgent or STAT orders, resulting in faster diagnostic delivery and improved continuity of care.
- Maintained 100% HIPAA compliance and documentation accuracy across EPIC and MedStar systems, protecting sensitive health data and ensuring audit readiness.
OVERNIGHT SHIFT MANAGER
The Community Partnership for the Prevention of the Homeless
Washington, D.C.
12.2017 - 08.2018
- Led nightly shelter operations for families experiencing homelessness, ensuring a safe, trauma-informed environment while supporting resident stability, crisis intervention, and access to essential services.
- Supervised and coached a team of 48 employees, strengthening performance, accountability, communication, and compliance with DHS, shelter, and government regulations.
- Improved operational efficiency and safety by implementing proactive security protocols, reducing incidents and response times by 20%, while maintaining accurate documentation, incident reporting, case notes, and continuity of care.
Overnight Clerk
USPS
Glen Burnie, MD
03.2015 - 05.2017
- Processed and distributed 5,000+ pieces of mail daily with 99% accuracy, ensuring timely delivery of registered, certified, insured, and sensitive materials while maintaining compliance with USPS and federal regulations.
- Managed high-value government, legal, payroll, and confidential documents, maintaining strict chain-of-custody procedures, audit readiness, and zero loss incidents.
- Improved mail processing efficiency through workflow optimization, Business Reply Mail (BRM) administration, and cross-functional collaboration; served as a Passport Acceptance Agent, verifying identities and processing legal documentation in compliance with U.S. Department of State requirements.
Billing & Enrollment Technician, Quality Assurance
CareFirst BlueCross/BlueShield
Washington, D.C.
12.2000 - 05.2004
- Conducted quality assurance reviews of enrollment transactions, eligibility records, billing data, and account maintenance activities, identifying discrepancies and ensuring data integrity, accuracy, and regulatory compliance.
- Researched and resolved complex enrollment, eligibility, billing, and premium payment issues by collaborating with cross-functional teams, providers, brokers, and employer groups to ensure accurate account management and uninterrupted access to healthcare services.
- Analyzed enrollment and billing trends, monitored performance metrics, identified root causes of errors, and recommended process improvements to enhance operational efficiency, workflow accuracy, and customer satisfaction.
Education
High School Diploma -
Oxon Hill High School
Oxon Hill, MDProfessional Highlights
➢ Improved healthcare and government operations by reducing processing and scheduling errors by 30%+ through workflow optimization, CRM utilization, quality assurance initiatives, staff training, and HIPAA/CMS compliance.
➢ Led, coached, and developed cross-functional teams of up to 48 employees, enhancing operational performance, customer service delivery, audit readiness, regulatory compliance, and organizational effectiveness.
Core Competencies & Technology
- Healthcare Operations • Case Management • Appeals & Grievances • Prior Authorization • Claims Resolution • Care Coordination • Member Advocacy • Eligibility & Benefits Verification • Medicare, Medicaid & D-SNP Programs • HIPAA, CMS & NCQA Compliance • Regulatory Compliance • Quality Assurance • Process Improvement • Escalation Management • Root Cause Analysis • Data Analysis & Reporting • Documentation Management • Workflow Optimization • Customer Experience • Contact Center Operations • Cross-Functional Leadership Salesforce • ServiceNow • Zendesk • Microsoft Dynamics CRM • Help Scout • PowerBuilder • Epic • Cerner • Jira • Avaya • RingCentral • Microsoft Office Suite • Microsoft Teams • SharePoint • OneDrive • Google Workspace • Zoom • Webex • CRM Platforms • EMR/EHR Systems • Ticketing Systems • Workforce Management Tools • Call Center Technologies
Timeline
REMOTE SR CLIENT SERVICES REPRESENTATIVE
Telecommunications Development Corp
11.2025 - Current
REMOTE SENIOR CUSTOMER SERVICE REPRESENTATIVE
United Healthcare, UHG
10.2022 - 08.2025
RADIOLOGY PATIENT ACCESS REPRESENTATIVE
MedStar Washington Hospital Center
12.2018 - 08.2020
OVERNIGHT SHIFT MANAGER
The Community Partnership for the Prevention of the Homeless
12.2017 - 08.2018
Overnight Clerk
USPS
03.2015 - 05.2017
Billing & Enrollment Technician, Quality Assurance
CareFirst BlueCross/BlueShield
12.2000 - 05.2004
High School Diploma -
Oxon Hill High School