Quatrina Brown-Donnings
Riverview,Florida
Summary
Seasoned specialist offering several years of comprehensive experience interpreting and implementing quality assurance standards, investigating customer complaints and non-conformance issues. Practiced and knowledgeable professional possessing excellent problem solving and analytical skills, proficient with resolving department and company-wide issues through strategic department collaboration, to ensure a prompt, yet thorough response.
Detail-oriented, reliable, process-driven and proficient in problem solving while maintaining organizational structures as it relates to insurance billing and claims research, including Medicare and Medicaid plans within the health plan industry. Proficient in active listening with excellent communication skills, both verbal and written to bring about effective and timely resolutions for a diverse range of members and providers.
Flexible in fast-paced environments while remaining proficient in navigating multi-call center programs within a Windows-based environment, additionally experienced with Excel and other Microsoft Office programs. Skilled in multitasking and managing multiple platforms simultaneously across various workflows and managing competing priorities to ensure effective results.
Proactive, transformational, leader that utilizes motivational coaching to invoke a spirit of excellence in the work environment with a commitment to improving overall business processes.
Overview
14
14
years of professional experience
Work History
Executive Response Specialist
WellCare Health Plans Inc/Centene
06.2020 - Current
- Provide exceptional verbal and written communication to members and providers, focusing on ensuring resolutions to complaints, is clear and concise, yet empathetic and professional
- Coach, train, and mentor new and veteran team members regarding company policies, new procedures, and changes as it relates to members plan benefit design when addressing member/provider complaints
- Meticulously perform risk evaluations to investigate problems of an unusual nature in the area of responsibility to identify the root cause
- Consistently trusted to analyze issues that require additional research and special handling including regulatory, congressional, trust, marketing, sales, executive office, Centers for Medicare, and Medicare Services (CMS) as a subject matter expert
- Collaborate with various lines of business and departments to meet regulatory deadlines, while developing long- range goals that will be driven through to completion
- Extract data from a variety of relational databases and manipulate, explore data using quantitative, statistical, and visualization tools
- Taking ownership from a personal perspective to ensure continuous growth within the company.
Senior Grievance Coordinator
WellCare Health Plans, Inc
02.2020 - 06.2020
- Ethically coordinated the review of grievances to include preparing the case with all relevant documentation, scheduling the case, and processing the review conducted by the department’s consultant
- Served as a primary contact for escalated calls and/or escalated issues in which special care is required to enhance WellCare relationships with members and providers
- Functioned as a liaison between Claims, Enrollment, Billing, Member Services departments on data gathering and problem solving using HIPPA
- Recorded, investigated, and resolved over 300 customer complaints by using empathy, active listening, courtesy, politeness, helpfulness, as detailed in the Grievance Procedure narrative
- Provided mentorship to less senior team members and is accountable as a role model for customer service excellence
- Partnered with other departments including Appeals, Claims, Provider Relations, and Pharmacy to resolve member and provider issues
- Brainstormed, developed, and presented ideas for performance and process management improvement within the department.
Care Coordinator /Grievance
WellCare Health Plans, Inc.
01.2017 - 02.2020
- Professionally interacted with members, providers and other inquiries via telephone and correspondence(mail) for the Medicare/Prescription Drug Plan (PDP) lines of business regarding health care complaints and grievances
- Took ownership of the issue, completed the necessary research-utilizing all tools and resources to provide a professional, accurate and prompt resolution to the member and /or provider regarding their complaint and/or grievance, while staying in compliance with CMS guidelines
- Tracked and documented customer interactions and cases utilizing call center software and all available systems, including customer relationship management (CRM) by line of business for compliance and review to determine if there are any trends to be addressed and sent to the appropriate department for additional research and resolution
- Made decisions that are firm, fair, and consistent with the concept of a win-win-win for members, associates, and WellCare
- Translated department needs into a comprehensive project plan which ensures successful project completion resulting in increased audit scores and productivity
- Conversed with other departments including Claims, Intake, Enrollment and Member Services to create strategic plans to resolve member and provider issues via company access systems such as Teams and Microsoft (Email)
- Consistently met department productivity and performance metrics while adhering to assigned schedule
- Completed monthly participations in ongoing training ensuring proficiency in company policies, procedures, and CMS guidelines.
Program/ Referral Coordinator
Sunshine Health LTC (Centene Corp)
02.2015 - 01.2017
- Seeks to understand the complex needs of the member and provide excellent customer service to ensure all needs are met in a timely manner
- Prevented upper management escalations by resolving inbound calls from Case Managers, members, providers and other organizations regarding member documents and request for services
- Authored and mailed routine Plan of Care letters, signature requested documents, and educational materials
- Assisted in the medical and psychosocial aspects of utilization and coordinated care, which include initiating authorization requests for output or input services with the prior authorization list
- Obeying privacy regulations contacted the attending physician, member, or medical power of attorney, home health agencies and equipment vendors for information pertaining to special needs and completion of the staffing process for services to be rendered
- Coordinated services with over ten community-based organizations.
Patient Care Rep/Family Medicaid Hospice Medicaid
Med Assist
06.2011 - 12.2014
- Completed over 5k initial assets with patients and or their families, obtaining appropriate financial information to verify patient’s eligibility in applying for ICP, and Hospice Medicaid programs
- Educated patients about the criteria for hospice and ICP Medicaid metrics and in accordance with state income and asset guidelines; providing additional assistance in meeting income and asset criteria if needed with regards to establishing trust accounts and or asset depletion
- Scheduled over 500+ field visits to complete the application processed and obtain all necessary documents required to submit to DCF for verification
- Conduit for patients by following up with DCF to ensure all necessary documents have been received by the assigned case worker; acting as a point of contact between the patient, social worker, and nursing homes to insure appropriate approval time
- Investigated the patient's Medicaid status for Medically Needy Medicaid and verifying the patient’s share-of-cost has been met to submit bills to DCF for completion of bill tracking
- Advocated and researched the reason for patient's denial of benefits and submitting hearings regarding patients eligibly when needed.
Education
A.S Health and Human Service Management -
University of Phoenix
Business -
Crownd Queenz Professional Services (Notary)
Skills
- Xcelys
- Oracle
- Toolbox
- Microsoft Office Suite
- Workday
- Service Now
- Share Point
- PEGA
- ICarePath
- Adobe
- Teams
- Remote Work Environment
Timeline
Executive Response Specialist
WellCare Health Plans Inc/Centene
06.2020 - Current
Senior Grievance Coordinator
WellCare Health Plans, Inc
02.2020 - 06.2020
Care Coordinator /Grievance
WellCare Health Plans, Inc.
01.2017 - 02.2020
Program/ Referral Coordinator
Sunshine Health LTC (Centene Corp)
02.2015 - 01.2017
Patient Care Rep/Family Medicaid Hospice Medicaid
Med Assist
06.2011 - 12.2014
A.S Health and Human Service Management -
University of Phoenix
Business -
Crownd Queenz Professional Services (Notary)