Victoria Downey
Dravosburg
Summary
Experienced in a fast-paced environment, honed leadership and team management skills, consistently driving efficient operations and fostering team cohesion. Knack for problem-solving, conflict resolution, and performance improvement. Focus remains on achieving organizational goals. Eager to transition into a new position, leveraging transferable skills to make a meaningful contribution.
Overview
12
12
years of professional experience
1
1
Certification
Work History
Supervisor, Provider Disputes and Appeals
UPMC
08.2023 - Current
- Oversees daily operations of the complaints and grievance and provider appeal activities
- Ensures compliance with the National Committee for Quality Assurance, Department of Health, Department of Public Welfare and the Centers for Medicare and Medicaid Services requirements for complaints, grievances, and appeals
- Monitor the inventory of complaints, grievances, and appeals
- Ensure that the cases are assigned and processed according to regulatory and accrediting requirements
- Monitor cases for completeness, accuracy and timeliness
- Based on the outcome of ongoing monitoring, implement changes to promptly address noted non-compliance issues with re-measurement to ensure compliance
- Evaluate the department processes and make recommendations to improve operational performance
- As needed, assist with investigations and processing of complaints, grievances, and appeals
- When barriers are identified, intercede with other health plan staff members or external customers as needed to ensure compliance with requirements
- Supervise and monitor ongoing performance of team members
- Assess staff competencies and areas for growth
- Provide feedback to staff to assist them in meeting goals
- Continually examine team performance against department standards
- Assess needs for staff training and development
- Assist in the development of training materials and training for staff
- Maintain a positive work environment through employee recognition and interaction
- Adjust staff schedules to ensure compliance with requirements for complaints, grievances, and appeals
- Prepare staff performance reviews
- Participate in interviewing, hiring, and training of team members
- Assist manager in the analysis of complaints, grievances and appeals and in the identification of root causes
- Collaborate with other departments or external customers in the identification of opportunities and the development of action plans
- Manage the department in the absence of the manager
- Monitor and prepare routine reports
- Review and revise department policies and procedures
- Review regulations and requirements governing the complaint, grievance, and appeal processes to ensure compliance with new or revised requirements
- Assist in the preparation for external surveys, audits, or reviews of department processes
- Submission of executive complaint resolutions to executive leadership
- Manage special projects
Supervisor, Provider Advocate- CHC
UPMC
05.2022 - 08.2023
- The Supervisor, Provider Advocate acts as an advocate for Health Plan customers (member, provider, facilities, etc.) by providing guidance, interpretation and education on eligibility levels, benefit design, claim status, and various customer related inquiries
- The Supervisor is responsible for daily operations of a Customer Service Team and the daily oversight and front-line management of Provider Advocate team members
- The Supervisor will manage daily staffing, develop, and provide training to team members, assess the operational patterns of calls into the center and make recommendations to improve performance
- To successfully perform the role the Supervisor must understand the causes of customer concern and can communicate these findings to Call Center Management as well as various internal and external parties
- The Supervisor must use their knowledge and understanding of call trends and other information generated by numerous sources to identify opportunities to improve call center performance
- Furthermore, the position requires the ability to articulate these opportunities to internal and external audiences, implement the solutions, and track and monitor progress
- These functions must be done while also weighing the practical considerations and potential barriers that need to be overcome to successfully implement new programs and processes
Staff Development Specialist
UPMC
02.2021 - 05.2022
- Documented and maintained training records and database of related curriculum materials
- Created and implemented training programs for new employees, resulting in improved morale and better skills development
- Assisted with staff development by implementing effective, hands-on training programs for new employees, maximizing performance and engagement from day one
- Created and offered additional materials to enhance training
- Explained goals and expectations required of trainees
- Documented training activities and changes to analyze program effectiveness
- Created practice exams and exercise documents
Coaching and Engagement Lead
UPMC
06.2019 - 02.2021
- Complete special projects as assigned
- Assume supervisory responsibility in the absence of the supervisor
- Prepares and supports the delivery of Power Summits and Team Meetings
- Ensuring that one-on-one, staff coaching, and surveys are being completed
- Act as a mentor for other team leads and staff
- Evaluate team performance reports from production systems in the moment and weekly/monthly, review with leadership and team members and drive performance improvements
- Monitor contacts/inventory throughout the day and adjust the resources
- Participate in corporate/department trainings
- Provide technical and plan support to the Member/Provider Services Areas
- Assist with the team attainment of designated call service standards
- Ensure excellent customer satisfaction for both internal and external customers
- Effectively monitor calls queues and volumes
- Assist with the development and training of new team members
- Respond to customer requests and inquiries in a timely and accurate manner in keeping with Health Plan Policies and Procedures, Department of Public Welfare (DPW) laws and standards, Department of Insurance (DOI) laws and standards, Department of Health (DOH) laws and standards, Department of Health and Human Services (DHHS), Health Care Financing Administration (HCFA), and National Committee for Quality Assurance (NCQA) standards
Provider Advocate
UPMC
04.2018 - 06.2019
- Interfaced with providers by telephone or correspondence to answer inquiries and resolve concerns
- Actively maintained worklists open cut logs and follow up within the designated time standards
- Maintained or exceeded designated quality standards
- Identify any area of concerns that may compromise client satisfaction
- Participated in team meetings, provide ideas and suggestions to ensure client satisfaction and promote teamwork
- Responded to customer requests and inquiries in a timely and accurate manner
Title Examiner
Inspire Closing Services
06.2016 - 03.2018
- Designed electronic file systems and maintained electronic and paper files
- Wrote reports and correspondence from dictation and handwritten notes
- Organized files, developed spreadsheets, faxed reports and scanned documents
- Received and screened a high volume of internal and external communications, including email and mail
- Verified that information in the computer system was up-to-date and accurate
- Verified and logged in deadlines for responding to daily inquiries
- Processed confidential tax form information and verified applicants had adequate insurance
Front End Supervisor
Ross Dress for Less
06.2013 - 06.2016
- Answered questions regarding the store and its merchandise
- Greeted customers and ascertained customers' needs
- Helped customers with questions, problems and complaints in person and via telephone
- Stocked shelves and supplies and organized displays
- Organized racks and shelves to maintain the visual appeal of the store
- Verified that all customers received receipts for purchases
- Developed positive customer relationships through friendly greetings and excellent service
- Trained and served as a peer coach for new sales associates
Education
Bachelor of Arts - Sociology
Saint Leo University
Saint Leo, FL10.2023
High School Diploma -
Pennsylvania Cyber Charter School
Midland, PA01.2012
Skills
- Orientation procedures
- Team-building activities
- Training program development
- Leadership
- Work ethic
- Goal-oriented
- Issue and conflict resolution
- Collaboration
- Communication
- Decision Making
- Friendly, positive attitude
- Teamwork and collaboration
- Customer service
- Problem-solving
- Time management
- Attention to detail
- Organizational skills
- Calm under pressure
- Training and mentoring
- Staff management
- Job applicant interviews
Certification
- Six Sigma Certification
Timeline
Supervisor, Provider Disputes and Appeals
UPMC
08.2023 - Current
Supervisor, Provider Advocate- CHC
UPMC
05.2022 - 08.2023
Staff Development Specialist
UPMC
02.2021 - 05.2022
Coaching and Engagement Lead
UPMC
06.2019 - 02.2021
Provider Advocate
UPMC
04.2018 - 06.2019
Title Examiner
Inspire Closing Services
06.2016 - 03.2018
Front End Supervisor
Ross Dress for Less
06.2013 - 06.2016
High School Diploma -
Pennsylvania Cyber Charter School
Bachelor of Arts - Sociology
Saint Leo University
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