Tanya Brown
Quantum Health
Dublin,OH
12
years of professional experience
Dedicated and analytical professional with extensive experience in healthcare operations, provider relations, appeals and grievances, disability claims management, and data analysis. Skilled in researching complex issues, identifying financial impacts, improving operational workflows, and collaborating across departments to drive effective resolutions. Recognized for strong communication, leadership, technical expertise, and the ability to adapt quickly to evolving business needs. Seeking an opportunity with a company where I can continue to utilize and expand my analytical, technical, and leadership skills while contributing to organizational growth and success.
Work History
Patient Service Representative
1 Year 2 Months- Acted as the primary point of contact for patients and healthcare members, delivering exceptional customer service and support regarding healthcare benefits, claims, eligibility, and care coordination.
- Facilitated scheduling of appointments, verification of insurance coverage, and resolution of billing or claims-related concerns, enhancing patient access to services.
- Demonstrated empathy and effective communication when assisting members through complex healthcare situations.
- Reviewed and interpreted healthcare plan information to educate members on available services, treatment options, and coverage guidelines.
- Coordinated with healthcare providers, insurance carriers, and internal departments to resolve complex member issues, ensuring timely and effective resolutions.
- Collaborated with healthcare providers, insurance carriers, and internal departments to resolve complex member issues efficiently and professionally.
- Managed high-volume inbound and outbound communications while maintaining professionalism and attention to detail.
- Identified recurring issues and recommended workflow enhancements during process improvement initiatives to elevate the overall member experience.
Senior Disability Examiner
3 Years 3 Months- Reviewed and interpreted complex medical documentation, including diagnostic testing, operative reports, and physician office notes, to determine disability status.
- Analyzed, approved, and authorized disability claims while determining benefits eligibility in accordance with disability plan provisions.
- Communicated with healthcare providers to establish return-to-work expectations and coordinate disability management plans.
- Managed claims payments, approvals, and benefit adjustments for Workers’ Compensation, Social Security Disability Income (SSDI), and other offsets to ensure compliance and efficiency.
- Ensured compliance with duration control guidelines and plan provisions through ongoing medical management of claims.
- Maintained clear communication with claimants and clients regarding claim status, documentation requirements, payment information, and timelines through phone and written correspondence.
- Coordinated investigative efforts and conducted reviews of contested claims to support fair adjudication and resolution.
- Evaluated and arranged referrals for independent medical evaluations, surveillance, physician advisor reviews, functional capacity evaluations, and related services.
- Negotiated return-to-work accommodation with employers and physicians when appropriate.
- Referred complex cases to clinical case management and leadership teams as needed.
- Maintained professional relationships with clients, providers, and internal stakeholders to facilitate effective communication and collaboration.
Lead, Provider Inquiry & Resolution
1 Year- Led a team across multiple lines of business within the Provider Inquiry & Resolution department.
- Recognized as a Subject Matter Expert (SME) for MMP (Dual Medicaid/Medicare) and Marketplace lines of business.
- Ensured representatives accessed current training materials and resources to effectively manage provider payment disputes, claim appeals, and Ohio Department of Medicaid inquiries.
- Reviewed representative audits and conducted one-on-one coaching sessions, enhancing performance and accuracy.
- Provided guidance and clarification to internal departments regarding Medicare and Marketplace business lines.
- Collaborated cross-functionally to resolve system configuration, enrollment, claims processing, and code editing issues.
- Strengthened leadership, communication, coaching, and team collaboration skills through daily operational support and mentoring responsibilities.
Specialist, Appeals & Grievances
2 Years- Managed weekly reporting to identify, analyze, and monitor financial impacts caused by configuration errors, incorrect code edit denials, and claims processing issues.
- Resolved complex technical inquiries through extensive research and analysis.
- Assisted with complex technical inquiries requiring advanced research and analysis.
- Collaborated in the creation of a cross-functional committee involving multiple departments to resolve identified financial and operational issues impacting providers and the organization.
- Timeframes for correction
- Number of impacted providers
- Resolution strategies and payment corrections
- Reported findings and corrective actions to the State of Ohio Medicaid in accordance with provider agreements.
- Coordinated timely provider notifications on identified issues, estimated resolution timelines, and payment corrections to enhance communication and transparency.
- Conducted User Acceptance Testing (UAT) on updated system configurations by reviewing updated reporting and validating claims accuracy.
- Analyzed claims impact reports to ensure claims adjudicated correctly according to provider agreements.
- Provided monthly operational and financial impact updates to senior management.
- Collaborated with Project Management and Data Analytics teams to develop reliable reporting solutions, ensuring accurate and timely financial data for decision-making.
- Assisted in identifying required data elements, testing report accuracy, and providing ongoing feedback throughout a year-and-a-half-long reporting enhancement initiative.
Associate Representative, Provider Inquiry & Resolution
2 Years 2 Months- Handled provider inquiries through phone, email, and Ohio Department of Medicaid inquiries, ensuring timely and accurate responses.
- Conducted detailed research using multiple data sources to resolve claim issues involving health plan configuration, billing errors, prior authorization requirements, and manual calculation discrepancies.
- Reviewed Ohio Administrative Code (OAC) guidelines to ensure Medicaid Managed Care Plan compliance.
- Analyzed and compared provider-submitted data against Molina claims data using Microsoft Excel and SSRS reporting tools, identifying discrepancies and facilitating resolution.
- Articulated resolutions to providers via phone and email, enhancing understanding of findings and outcomes related to claims.
- Developed a strong understanding that effective issue resolution includes provider education and transparency.
Senior Representative, Member Services
1 Year 5 Months- Managed incoming provider calls, addressing claims processing and support inquiries to ensure timely resolutions.
- Handled incoming provider calls regarding claims processing and provider support inquiries.
- Verified claims accuracy and ensured proper adjudication.
- Trained and mentored new employees on provider customer service procedures and company policies to enhance team competency.
- Conducted training sessions across various Molina Medicare plans in multiple states on customer service standards and Medicare guidelines to ensure consistent service delivery.
Skills
Healthcare Claims & Benefits Knowledge
Insurance Verification
Claims Processing & Analysis
Medicare & Medicaid Knowledge
Ohio Department of Medicaid (ODM) Guidance
HIPAA Compliance
Medical Terminology
Data Entry & Documentation
Data Analysis & Trend Identification
Financial Impact Analysis
User Acceptance Testing (UAT)
Power BI Reporting
Microsoft Excel
Healthcare systems navigation
Patient support
Conflict resolution
Provider education
Relationship management
Process Improvement
Cross-functional collaboration
Time management
Cross-functional collaboration
Timeline
Patient Service Representative
Quantum Health
05.2025 - CurrentRead More
Senior Disability Examiner
Sedgwick
10.2021 - 01.2025Read More
Lead, Provider Inquiry & Resolution
Molina Healthcare
01.2020 - 01.2021Read More
Specialist, Appeals & Grievances
Molina Healthcare
01.2018 - 01.2020Read More
Associate Representative, Provider Inquiry & Resolution
Molina Healthcare
11.2015 - 01.2018Read More
Senior Representative, Member Services
Molina Healthcare
06.2014 - 11.2015Read More