Zhana Brown

• Manage an average of 50+ grievances and 40 appeals monthly, meeting 100% of regulatory turnaround requirements.

• Conduct clinical and non‑clinical reviews to determine case validity and required level of appeal.

• Draft decision letters and member notifications with 98% accuracy, minimizing re‑work and escalations.

• Collaborate with providers, legal, and clinical teams to gather supplemental information, reducing cycle time by 15%.

• Analyze grievance trends and recommend process improvements that cut member escalations by 25%.

• Produce weekly KPI reports on volume, resolution rates, and backlog for leadership review.

• Generated weekly spreadsheets summarizing case volumes and turnaround metrics for quality‑assurance meetings.

• Review clinical records and payer policy to prepare peer‑to‑peer summaries; achieved a 70% reversal rate on first appeal.

• Process an average of 200 ROI requests per month—including patient requests, attorney subpoenas, and insurance authorizations—while maintaining 100% regulatory compliance.

• Achieve 98% first‑pass accuracy in record delivery through rigorous QA checks and standardized documentation workflows.

• Reduce average request turnaround time from 7 to 3 business days by implementing an electronic tracking system.

• Coordinate with legal and risk‑management teams to handle urgent subpoenas and court orders, ensuring timely response

• Navigate EMR systems (Epic, Cerner, Meditech) to locate requested documentation

• Ensure all releases adhere to HIPAA, state privacy laws, and organizational policies

• Prepare records in the requested format (PDF, CD, secure portal upload, fax, mail)

• Serve as primary liaison for requestors—answer status inquiries, clarify request details, and troubleshoot issues

• Reviews accounts, and initiate pre-authorizations, and other requirements related to

managed care; route to appropriate departments as needed.

• Collects demographic, insurance, and clinical information to ensure that all reimbursement

requirements are met.

• Notifies the necessary parties within the required timeframe for routine and urgent requests

for services.

• Assists in monitoring utilization services to assure cost effective use of medical resources

through processing prior authorizations.

• Communicates with patients and/or referring physicians on non-covered benefits or

procedure coverage issues.

• Assists with medical necessity documentation to expedite approvals and ensure that

appropriate follow-up is performed.

• Provides consistent and comprehensive information (both in writing and verbally) to facilitate

approvals.