Shontay Cole

Grievance and Appeals Coordinator II with experience managing and resolving grievances and appeals for Medicare, Medicaid, Medi-Cal, AIP, C-SNP, and D-SNP members. Conducted research, investigations, documentation, and resolution of member complaints, authorizations, grievances, and appeals using verbal and written communications aligned with CMS regulations and organizational policies. Committed to ensuring timely, accurate resolutions while maintaining compliance and delivering exceptional member service.

• Coordinated resolution of member appeals and grievances, collaborating with relevant parties to achieve timely outcomes.
• Analyzed complex cases to determine appropriate resolution in accordance with relevant laws, regulations and organizational policies.
• Documented appeal processes and outcomes to ensure compliance with regulations and facilitate accurate reporting.
• Facilitated discussions on challenges and solutions in team meetings, contributing to collective problem-solving efforts.
• Called insurance companies to ascertain pertinent information regarding policies and payment benefits for patients.

Department of Defense TRICARE Prescription Monitoring Program (Remote, C2 Security Clearance). Collaborate closely with senior care management teams to support care coordination activities and ensure members receive timely, appropriate services from healthcare providers and network partners. Monitor and facilitate continuity of care, address barriers to service delivery, and coordinate with interdisciplinary teams to promote positive health outcomes, member satisfaction, and compliance with program requirements.

• Coordinated patient care plans with healthcare providers and community resources.
• Managed patient records using electronic health record systems.
• Obtained insurance authorizations for prescribed medications or treatments for patients in need of financial assistance programs.
• Relayed messages from patients to physicians about concerns, condition updates or refill requests to facilitate treatment.
• Scheduled appointments for patients via phone and in person.
• Ensured confidentiality of patient information to maintain trust and comply with regulations. and maintained patient confidence by completing and safeguarding medical records.
• Supported administrative tasks, including billing and insurance verification.

DME Manager with extensive experience managing high-volume workloads in fast-paced healthcare environments. Skilled in interpreting, updating, and maintaining Electronic Medical Records (EMRs), coordinating intake activities, and handling a large volume of inbound and outbound calls. Demonstrates expertise in prior authorization research, processing, submission, follow-up, and completion, ensuring timely approvals and continuity of care. Possesses comprehensive knowledge of durable medical equipment (DME) operations, including billing and coding practices, HCPCS and ICD-10 coding, insurance verification, and compliance with HIPAA regulations and Protected Health Information (PHI) standards. Experienced in dispatching, scheduling, routing, processing, and verifying new, aged, and complex orders while collaborating with providers, payers, and patients to ensure efficient service delivery, regulatory compliance, and exceptional patient care.

• Managed billing processes for claims submission to Medicare, Medicaid, and private insurance, ensuring accurate and timely payment.
• Resolved discrepancies in invoices from suppliers for durable medical equipment purchases, maintaining strong vendor relationships.
• Implemented quality assurance measures to verify accuracy of orders placed for DME products or services.
• Recorded and organized patient information, including insurance coverage, billing details, and delivery logistics, to support efficient service delivery.
• Collaborated with healthcare professionals to determine appropriate DME solutions for patients' needs.
• Assisted with troubleshooting technical issues related to the use of DME equipment.

Medical Intake and Authorization Coordinator with extensive experience coordinating intake for wound care supplies, ostomy products, durable medical equipment (DME), and urological supplies. Skilled in managing complex care authorizations, insurance verification, prior authorization research, processing, follow-up, and completion to ensure timely access to medically necessary services. Possesses comprehensive knowledge of full-cycle billing processes for enteral nutrition and negative pressure wound therapy (NPWT), including claim review, reimbursement procedures, and payer requirements. Experienced in applying medical billing and coding principles, navigating healthcare payer guidelines, and collaborating with providers, insurance carriers, and patients to facilitate efficient order processing and continuity of care. Demonstrates a strong understanding of healthcare regulations, documentation standards, and compliance requirements while delivering accurate, high-quality service in fast-paced clinical environments.

• Managed patient intake procedures effectively and documented necessary information accurately.
• Guided patients in understanding insurance coverage and financial responsibilities, ensuring informed decisions about their healthcare options.
• Formulated customized service plans based on client needs for each client based on their unique needs and goals.
• Adhered to industry regulations governing service provision.
• Facilitated referrals to community resources and agencies, connecting clients with essential support services tailored to their needs.
• Executed crisis intervention strategies to assist clients.
• Observed client development and recorded case file changes and updated case files accordingly.
• Executed risk assessments to identify immediate concerns for intervention, prioritizing client safety and timely support.

Health Services / Appeals and Authorizations Specialist with extensive experience resolving patient and member concerns within established regulatory timelines and service-level requirements. Skilled in researching, reviewing, and re-evaluating electronic and manual claims, denied authorizations, appeals, grievances, billing inquiries, and scheduling concerns. Experienced in providing accurate, detailed, and member-focused guidance regarding coverage determinations, prior authorizations, step therapy requirements, claim adjudication, and appeal rights. Demonstrated ability to interpret complex healthcare benefits, investigate claim and authorization issues, and coordinate with providers, health plans, and members to facilitate timely resolutions. Strong knowledge of healthcare regulations, medical necessity criteria, claims processing, utilization management, and customer advocacy, with a commitment to ensuring compliance, continuity of care, and positive member outcomes.

• Guided patients in navigating healthcare processes by verifying insurance coverage and clarifying benefits, enhancing their understanding and access to care.
• Collaborated with medical staff to optimize patient flow and care coordination, improving overall patient experience.
• Managed incoming calls from patients, providers, and insurance companies, ensuring accurate information delivery and fostering positive relationships.
• Maintained medical records through systematic filing by filing documents into appropriate folders according to established protocols.
• Processed referrals from primary care providers for specialist consultations or treatments.
• Recorded patient data regarding health status and history and documented records of health condition, hospitalizations and lifestyle patterns.
• Acted as liaison between physicians, staff members, patients, families, and third party payers.