Summary
Overview
Work History
Education
Skills
Timeline
Generic

Katlynn Toifel

Mobile,AL

Summary

Results-driven healthcare and sales professional with experience in Medicare escalations, prior authorization processing, and outbound sales. Skilled at resolving complex member and provider issues, ensuring regulatory compliance, and delivering exceptional customer service. Demonstrated expertise in Medicare Advantage and Part D guidelines, pharmacy benefit management, and clinical case review, as well as sales strategy, lead generation, and closing new accounts. Proficient in CRM and PBM systems including Salesforce, RxCLAIM, MedAccess, QNXT, and Microsoft Office Suite. Known for strong problem-solving, communication, and process improvement skills, consistently achieving quality, productivity, and performance targets.

Overview

5
5
years of professional experience

Work History

Operations Rep II

CVScaremark
07.2024 - 07.2025
  • Processed and adjudicated prior authorization requests for Medicare, Medicaid, and commercial members in compliance with clinical guidelines, plan benefits, and CMS regulations.
  • Reviewed and interpreted clinical documentation, treatment history, and diagnostic information to determine coverage eligibility for prescribed medications.
  • Communicated PA determinations and next steps to providers, pharmacies, and members, ensuring timely resolution within required regulatory timeframes.
  • Collaborated with pharmacists, nurses, and clinical review teams to resolve complex or escalated cases requiring additional clinical judgment.
  • Maintained 100% compliance with documentation standards, entering accurate case notes into PBM systems for audit readiness and quality reporting.
  • Assisted prescribers and members in navigating alternative formulary options and tiered medications when coverage was denied.
  • Consistently met or exceeded departmental productivity and accuracy metrics, averaging 27 cases processed per day with 90% quality rating.

Medicare Escalations

Results Companies
02.2022 - 01.2025
  • Manage and resolve complex Medicare Advantage and Part D escalations, including member complaints, provider disputes, and regulatory inquiries, ensuring compliance with CMS guidelines and internal policies.
  • Investigate cases by coordinating with claims, pharmacy, utilization management, and compliance departments to determine root cause and provide accurate resolutions.
  • Draft and deliver formal written responses to members, providers, and regulatory agencies within strict CMS timeframes.
  • Serve as an advocate for Medicare beneficiaries, addressing concerns with professionalism and maintaining high levels of member satisfaction.
  • Document and track cases in compliance systems for audit readiness and regulatory reporting.
  • Collaborate with compliance and quality improvement teams to identify trends and implement process improvements that reduce repeat escalations.
  • Consistently exceeded departmental performance standards, including case turnaround time and accuracy metrics.

Outbound Sales Representative

ADT
08.2020 - 02.2022
  • Conducted outbound sales calls to prospective and existing customers, presenting ADT’s home security and smart home solutions.
  • Performed needs assessments and recommended tailored security packages to meet customer requirements.
  • Effectively handled objections, negotiated pricing, and closed sales, consistently meeting or exceeding monthly quotas.
  • Scheduled installation appointments and ensured seamless transition from sales to service teams.
  • Maintained accurate records of customer interactions and sales activity in CRM systems.

Education

Dothan High School
Dothan, AL
05.2018

Skills

  • Medicare Advantage & Part D Knowledge
  • CMS Regulatory Compliance
  • Grievance & Appeals Case Management
  • Root Cause Analysis & Problem Resolution
  • Written Communication & Compliance Letters
  • Systems Used: Salesforce CRM, Facets, QNXT, SharePoint, Microsoft Office Suite, Internal Case Tracking Platforms, Marx, Pega,& Mhk
  • Outbound Sales & Cold Calling
  • Customer Needs Assessment
  • Objection Handling & Negotiation
  • CRM Systems: Salesforce, Five9, Genesys Cloud, ADT Sales Portal
  • Call Center / Dialer Systems
  • Customer Relationship Management
  • Smart Home & Security Solutions Knowledge
  • Prior Authorization Processing (Medicare Part D, Medicaid, Commercial)
  • CMS & State Regulatory Compliance
  • Clinical Criteria Application & Case Review
  • Provider, Pharmacy, and Member Communication
  • Audit & Quality Documentation Standards
  • Systems Used: RxCLAIM, MedAccess, Salesforce CRM, Microsoft Office Suite, Internal Prior Authorization Platforms

Timeline

Operations Rep II

CVScaremark
07.2024 - 07.2025

Medicare Escalations

Results Companies
02.2022 - 01.2025

Outbound Sales Representative

ADT
08.2020 - 02.2022

Dothan High School
Katlynn Toifel