Anjelica Shines
San Tan Valley,AZ
Summary
Experienced healthcare professional with comprehensive training and hands-on experience. Proven track record supporting medical teams in delivering high-quality patient care and maintaining clinical standards. Recognized for collaborative spirit and adaptability in dynamic environments, leveraging strong organizational and interpersonal skills. Background in healthcare, prepared for this role with a strong ability to adapt to changing needs and effectively collaborate with teams. Skills include patient care, medical terminology, and basic clinical procedures. Reliable and results-driven, focused on achieving positive health outcomes and maintaining high standards. Demonstrated exceptional customer service within the healthcare industry. Effective in managing patient inquiries and resolving issues promptly, contributing to high patient satisfaction. Possesses strong communication and problem-solving skills to ensure seamless patient experiences and operational efficiency.
Overview
8
8
years of professional experience
1
1
Certification
Work History
Desk Structure Property Claims Adjuster
American Family Insurance
05.2024 - Current
- Exercised proper judgment and decision making to analyze over 17 claims per week.
- Enhanced customer satisfaction with prompt communication and consistent follow-up on claim status updates.
- Achieved timely resolution of property claims by investigating, evaluating, and settling a variety of cases.
- Reduced company expenses by accurately determining coverage and negotiating cost-effective settlements with policyholders.
- Streamlined the claims process for increased efficiency by consistently updating claim files and maintaining accurate records.
- Managed high caseloads effectively by prioritizing tasks based on complexity and urgency of claims.
- Collaborated with contractors to verify repair estimates, ensuring fair settlements for both policyholders and company.
Prior Authorization Referral & Notification Representative
Banner Health
03.2023 - 05.2024
- Provided exceptional customer service, addressing inquiries from both patients and healthcare providers promptly and professionally.
- Verified eligibility and compliance with authorization requirements for service providers.
- Ensured compliance with HIPAA regulations by maintaining strict confidentiality in handling sensitive patient information.
- Improved patient satisfaction by efficiently processing prior authorization requests and ensuring timely responses.
- Collaborated with healthcare providers to expedite processes of obtaining necessary medical documentation for approvals.
- Increased customer satisfaction by addressing and resolving complaints in a timely manner.
Coding Specialist
SnF Management, LLC
08.2021 - 02.2023
- Responsible for auditing the ICD-10 coding of 30 skilled nursing facilities to ensure accuracy and proper reimbursement before being submitted to Medicare and other insurance providers
- Developed company-wide ICD-10 training in conjunction with Administrators, Director of Nursing, MDS Coordinators, medical records/health information department, and business office managers.
- Maintained compliance with coding guidelines.
- Ensured accuracy in coding through regular audits, identifying discrepancies and areas for improvement.
- Accomplishments:
- Implemented company-wide ICD-10 monthly training for MDS Coordinators
- Improved ICD-10 coding compliance from 35% company-wide to over 90%
- Managed all ICD-10 coding for 30 skilled nursing facilities
Membership & Enrollment Specialist
Bright Healthcare
12.2020 - 08.2021
- Researched, investigated and resolved discrepancies in enrollment activities, as well as member disputes concerning billing
- Identified mistakes, omitted information, and missing forms and attachments and relayed the information as required to ensure timely completion
- Responded to email requests for information and telephone inquiries from members, brokers or agents, in a courteous manner
- Worked cross-functionally with other departments to develop or review processes and to resolve member issues
- Ensured all work activities are carried out in accordance with the confidentiality requirements mandated for member information
Member Advocate Supervisor
Maxor Plus
08.2019 - 12.2020
- Coordinated and monitored operational activities of call center including quality service, workflow, and workforce optimization
- Handled escalated customer complaints and resolved service issues/member concerns by providing appropriate solutions/information to ensure maximum customer satisfaction
- Worked with managers/superiors to provide work environment and culture that promotes customer service, staff development, and achievement of set objectives
- Communicated performance objectives including technical support and customer service to team members, ensuring compliance with company and department policies
- Maintained quality control/satisfaction records, and constantly sought new ways to improve customer service.
Consumer Services Analyst
Early Warning Services, LLC
02.2019 - 08.2019
- Gathered, analyzed, and utilized relevant data to develop ways to improve overall user experience on site
- Engaged with consumers, responded to inquiries/complaints, investigated and resolved reported issues on social media such as requests for account support and reports of potentially abusive content; escalated issues as required
- Supported company's commitment to protect integrity and confidentiality of data
Customer Inquiry Billing Specialist
Apria Healthcare
03.2018 - 02.2019
- Responded to patient general inquiries, information updates, and billing questions while promptly resolving problems and concerns accurately and professionally
- Utilized multiple operating systems to obtain information that would facilitate claim payment, enter necessary insurance data, and refill claims with insurance companies
- Reviewed patient information for accuracy and completeness, and updated patient demographics and insurance information as needed
- Built customer loyalty by promptly responding to inquiries/concerns, finding solutions, and resolving patient issues
- Maintained highest levels of accuracy and patient confidentiality
Eligibility Specialist
Group Administrators Ltd
09.2017 - 01.2018
- Provided services to Human Resource representatives of small companies by setting up their employees medical, dental, and vision plans
- Scheduled individual screening and eligibility appointments to decipher employee’s suitability for each program
- Initiated procedures to grant, deny, modify or eliminate eligibility/delete dependents based on set principles
- Ascertained that all eligibility and intake information is properly handled while paying special attention to confidentiality
- Maintained complete and accurate computerized and/or paper records of client eligibility; updated and changed statuses when required
- Enhanced client satisfaction by providing timely and accurate eligibility determination for various assistance programs.
- Reduced errors in eligibility determinations by maintaining thorough knowledge of program guidelines and regulations.
- Provided exceptional customer service through prompt response times, clear communication channels, and diligent follow-up practices.
- Ensured compliance with local, state, and federal regulations during all phases of eligibility determination process.
Prior Authorization Technician
OptumRX
12.2016 - 09.2017
- Tracked and triaged coverage determination requests submitted from providers and determined if pharmacist review is required
- Obtained verbal authorizations and requested detailed clinical information from prescribers
- Adhered strictly to company policies, procedures, processes, and standards, as well as maintained knowledge of member benefits, rights and responsibilities
- Notified physicians, providers, and members of coverage determination request decisions or of any delays in obtaining authorizations
- Verified eligibility and compliance with authorization requirements for service providers.
- Tracked referral submission during facilitation of prior authorization issuance.
- Fielded telephone inquiries on authorization details from plan members and medical staff.
- Obtained and logged accurate patient insurance and demographic information for use by insurance providers and medical personnel.
Education
Bachelor of Science - Nursing
Arizona College of Nursing
Tempe, AZ08-2026
Medical Assisting -
Everest College
Burr Ridge, IL11.2010
Diploma -
Downers Grove South High School
Downers Grove, IL01.2006
Skills
- Medical Coding
- Data Management
- Quality Assurance
- Medical & Pharmaceutical Terminology
- Operations Management
- CPT Coding
- ICD-9 Coding
- ICD-10 Coding
Certification
- ICD-10-CM Coding Certificate Program for SNFs + ICD-10-CM for PDPM
- Pharmacy Technician License
- Licensed Independent Insurance Adjuster – [All states] Department of Financial Services or equivalent regulatory body where licensing is required by the state.
References
Available upon request
Timeline
Desk Structure Property Claims Adjuster
American Family Insurance
05.2024 - Current
Prior Authorization Referral & Notification Representative
Banner Health
03.2023 - 05.2024
Coding Specialist
SnF Management, LLC
08.2021 - 02.2023
Membership & Enrollment Specialist
Bright Healthcare
12.2020 - 08.2021
Member Advocate Supervisor
Maxor Plus
08.2019 - 12.2020
Consumer Services Analyst
Early Warning Services, LLC
02.2019 - 08.2019
Customer Inquiry Billing Specialist
Apria Healthcare
03.2018 - 02.2019
Eligibility Specialist
Group Administrators Ltd
09.2017 - 01.2018
Prior Authorization Technician
OptumRX
12.2016 - 09.2017
Diploma -
Downers Grove South High School
- ICD-10-CM Coding Certificate Program for SNFs + ICD-10-CM for PDPM
- Pharmacy Technician License
- Licensed Independent Insurance Adjuster – [All states] Department of Financial Services or equivalent regulatory body where licensing is required by the state.
Bachelor of Science - Nursing
Arizona College of Nursing
Medical Assisting -
Everest College
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