Rain Burleson
Clayton,NC
Summary
Healthcare professional with experience in managed care, care navigation, and quality improvement. Proven ability to improve care delivery by bridging communication between providers, patients, and health plans. Adept at identifying care gaps, ensuring regulatory compliance, and driving measurable improvements in healthcare outcomes. Skilled in building strong provider and patient relationships, managing risk, and fostering collaborative environments to support organizational goals.
Overview
10
10
years of professional experience
Work History
Associate, Quality Operations
Pomelo Care
Remote
04.2025 - Current
- Supported quality and clinical operations across a digital maternal and family health platform, ensuring adherence to care protocols and operational standards.
- Managed and monitored key quality metrics, helping track doula performance, complaints and adverse events, and continuous improvement initiatives.
- Collaborated cross-functionally with clinical, operations, and technology teams to streamline doula and provider workflows, improve documentation accuracy, and support data integrity.
- Conducted audits and process reviews to ensure compliance with internal policies and regulatory requirements.
- Played a key role in onboarding new doulas and operational staff by developing and maintaining SOPs, training materials, and quality checklists.
- Oversaw client and doula incident tracking and reporting systems, analyzing trends and assisting in mitigation strategies.
- Maintained detailed records of quality events and contributed to root cause analyses and performance improvement planning.
- Supported the rollout of quality improvement initiatives and piloted new operational tools to enhance care delivery efficiency.
- Creating proposals and addressing pain points based on data collected from complaints and grievances
Provider Relations Representative/ Care Navigator
Arkos Health
Gilbert, AZ
05.2023 - 04.2025
- Fostered robust provider relationships to streamline care delivery, address service concerns, and enhance managed care efficiencies.
- Analyzed patient data to identify care gaps, ensuring compliance with HEDIS standards across Medicare, Medicaid, and Marketplace programs.
- Developed educational initiatives for providers on policies and procedures to improve compliance and care quality.
- Spearheaded quality and risk management improvements for multiple insurance lines, driving measurable enhancements in care outcomes.
- Utilized CRM tools to manage patient referrals and provider interactions, ensuring accuracy in care coordination and relationship tracking.
- Collaborated with cross-functional teams to grow the provider network, streamlining claims, contracting, and credentialing processes.
- Designed and implemented training materials to support new team member onboarding and improve operational workflows.
- Conduct outreach to high-risk patients, identifying care gaps and assessing needs via phone, mail, or in-person visits.
- Develop personalized care plans in collaboration with healthcare providers.
- Schedule and coordinate specialist appointments, follow-ups, and transportation support.
- Educate patients on diagnoses, treatment options, medication management, and preventative care.
- Identify and address social determinants of health affecting care access.
- Monitor patient progress, identify care gaps, and implement interventions to improve outcomes.
- Communicate effectively with healthcare teams to ensure coordinated care.
- Track patient data, document care interactions, and generate quality reports.
- Contribute to quality improvement initiatives to enhance patient outcomes and care processes.
- Advocate for patients by addressing their concerns and navigating healthcare systems.
- Understanding HEDIS, NCQA, and other quality measures
- Monitoring patient outcomes and care quality metrics
Front Office Lead
Live Well Wellness Center, Chandler
Chandler, AZ
12.2021 - 05.2023
- Led front office operations to enhance patient intake and scheduling, improving care access and patient satisfaction.
- Identified and addressed HEDIS quality gaps, scheduling patient appointments to collect necessary documentation for preventive care compliance.
- Created patient education programs on supplements and procedures to build trust and improve adherence to care plans.
- Expertly managed multifaceted role in patient care, including vitals assessment and hormone replacement therapy assistance, and patient education.
- Oversee daily front desk operations, ensuring smooth patient check-in/check-out processes.
- Train, mentor, and supervise front desk staff to maintain high customer service standards.
- Schedule and confirm patient appointments, optimizing provider schedules.
- Handle patient inquiries, complaints, and escalations professionally and efficiently.
- Verify insurance coverage, process authorizations, and handle billing inquiries.
- Maintain accurate patient records and ensure compliance with HIPAA regulations.
- Coordinate communication between front office staff, medical providers, and administrative teams.
- Manage office supplies, equipment, and inventory to ensure smooth operations.
- Implement and enforce office policies and procedures to improve efficiency.
- Generate reports on front office performance, patient flow, and scheduling metrics.
- Ensure a welcoming and professional environment for patients and visitors.
Patient Service Representative/Administrative Assistant
Tidewater Physicians Multi-specialty Group, Newport News
Newport News, VA
08.2020 - 08.2021
- Manage patient check-in and check-out processes efficiently, ensuring accurate documentation.
- Schedule, reschedule, and confirm appointments while minimizing scheduling conflicts.
- Verify patient demographics and insurance eligibility to ensure seamless billing and claims processing.
- Monitored and tracked HEDIS compliance, noting preventive care needs to close quality gaps in patient screenings and physicals.
- Facilitate communication between patients and medical staff regarding test results, prescriptions, and treatment plans.
- Participate in training sessions, meetings, and quality improvement initiatives to enhance service delivery.
- Coordinate with healthcare providers, nurses, and administrative staff to optimize patient flow.
- Upheld strict HIPAA compliance, safeguarding patient privacy and maintaining secure record-keeping practices in a multi-specialty healthcare environment.
- Trained new front office staff, fostering a cohesive team environment and ensuring consistent high-quality patient service standards.
- Assisted in vital collection as needed
- Process referrals and prior authorizations for specialist visits, diagnostic tests, and procedures.
- Collect copays, outstanding balances, and payments, providing accurate receipts and documentation.
- Educate patients on office policies, procedures, and available healthcare resources.
Medical Records Specialist
Tidewater Physicians Multi-specialty Group, Newport News
Newport News, VA
04.2020 - 08.2020
- Efficiently processed medical record requests per patient and provider service.
- Supported EHR system implementation, improving record management and staff training.
- Collaborated with healthcare teams to maintain accurate records amidst regulatory changes.
- Streamlined record digitization, enhancing data access and reducing retrieval time.
- Executed strategic record management protocols, including systematic removal of outdated records and deactivation of inactive patient charts.
- Managed patient records for compliance, and applied ICD-10/CPT coding, ensuring accurate and up-to-date medical documentation.
- Support automation and digitization of HEDIS-related processes to enhance efficiency
Personal Shopper
Instacart
Newport News, VA
04.2018 - 05.2019
- Using the app to accept orders, communicate with customers, modify orders, provide directions to customers' homes, and process payments.
- Processed payments seamlessly, adapting to fluctuating order volumes and preferences.
- Adhered to safety protocols, contributing to a clean and organized shopping environment.
- Ensured order accuracy by verifying product quality, expiration dates, and managing substitutions, minimizing errors and customer complaints
- Adapted to fluctuating order volumes and customer preferences, implementing creative solutions to maintain shopping efficiency and client satisfaction.
- Educated customers on app functionality, empowering them to make changes and improving their overall shopping experience with Instacart.
Stablehand
Areion Equestrian
Gloucester, VA
01.2016 - 02.2019
- Cared for horses by maintaining health, safety, and optimal stable conditions.
- Aided in exercise routines, ensuring the physical conditioning of horses.
- Monitored and reported health issues, facilitating timely veterinary care.
- Mentored junior staff in safe horse handling and best practices.
Dietary Aide
Virginia Health Services
Yorktown, VA
09.2015 - 12.2016
- Prepare and serve meals to residents according to dietary guidelines and restrictions.
- Assist in meal preparation, portioning, and plating while maintaining food safety standards.
- Deliver meals to residents rooms or dining areas, ensuring accuracy and timeliness.
- Follow prescribed diets and special meal plans to meet residents nutritional needs.
- Maintain cleanliness and sanitation in the kitchen, dining areas, and food service equipment.
- Assist with dishwashing, utensil sanitization, and proper food storage.
- Monitor food inventory and restock supplies as needed.
- Ensure proper labeling and dating of food items to comply with health regulations.
- Engage with residents in a friendly and respectful manner while assisting with meals.
- Follow all infection control and safety procedures to maintain a healthy environment.
- Work collaboratively with dietary staff, nursing teams, and caregivers to meet resident needs.
- Assist in setting up dining areas and cleaning up after meals.
- Report any concerns regarding residents dietary needs or intake to healthcare.
- Participate in staff training sessions and adhere to facility policies and procedures.
Education
Associates of Science -
Thomas Nelson Community College
High School Diploma -
York High School
Skills
- Customer Service
- Managed Care
- Risk Management
- Care Coordination
- Credentialing, Contracting, and Claims processing
- Onboarding
- Scheduling
- Provider/Patient Education
- Quality Improvement Management
- Utilization Management
- Business Process Improvement
- CPT/ICD-10 Coding
- Healthcare provider network management (Medicare, Medicaid, Marketplace)
- Data analysis and reporting
- Provider onboarding and training
- Healthcare management software (CRM)
- Insurance policies and procedures
- Relationship-building
- Electronic health record (EHR) management
- Case management and documentation
- Quality Improvement
Languages
English
Training
- CPC Coding, Ohana School for Coding
- January 2022 — March 2022
Timeline
Associate, Quality Operations
Pomelo Care
04.2025 - Current
Provider Relations Representative/ Care Navigator
Arkos Health
05.2023 - 04.2025
Front Office Lead
Live Well Wellness Center, Chandler
12.2021 - 05.2023
Patient Service Representative/Administrative Assistant
Tidewater Physicians Multi-specialty Group, Newport News
08.2020 - 08.2021
Medical Records Specialist
Tidewater Physicians Multi-specialty Group, Newport News
04.2020 - 08.2020
Personal Shopper
Instacart
04.2018 - 05.2019
Stablehand
Areion Equestrian
01.2016 - 02.2019
Dietary Aide
Virginia Health Services
09.2015 - 12.2016
Associates of Science -
Thomas Nelson Community College
High School Diploma -
York High School