Constantina Shipley
Sun Prairie,WI
Summary
Patient Financial Services Representative II with a focus on government payer denials, claim reprocessing, appeal follow-up, and benefit details in Epic professional billing. Reviews Medicare, Medicaid, and Medicare Advantage denials, verifies coverage and payable diagnosis codes, and documents account activity to support accurate reimbursement. Handles complex Precision Oncology denials tied to non-covered, experimental, and medical necessity decisions.
Overview
34
34
years of professional experience
Work History
Revenue Cycle, Patient Financial Services Representative II/Government Team
Exact Sciences Corporation
Madison, WI
11.2021 - Current
- Review government payer denials across Medicare, Medicaid, and Medicare Advantage for appeal, refile, or adjustment decisions.
- Verify coverage, diagnosis codes, and benefit details to confirm whether denied claims meet payer requirements.
- Contact payers directly to validate denial reasons, request claim reprocessing, and clarify explanation of benefits findings.
- Document all denial details, payer responses, and next steps in Epic professional billing account notes.
- Prepare appeal letters and initiate reimbursement requests for complex Precision Oncology denials involving non-covered, experimental, and medical necessity determinations.
- Assess authorization status and clinical criteria to determine whether charges qualify for coverage under specific payer rules.
Medicare Insurance Follow Up Specialist
SSM Health/Dean Medical Group
Madison, WI
08.2012 - 11.2021
- As an insurance follow up specialist I was responsible for working denied claims and no response claims to resolve outstanding accounts and ensure timely and accurate payment.
- Responsibilities included identifying denial trends and working with supervisor, manager to facilitate root cause analysis and continuous process improvement.
- Knowledge of HCPS, ICD10, medical terminology, federal and state regulations and payer rules as they pertain to professional billing.
- Experience working with Epic professional billing system.
Third Party Liability Processor
Wisconsin Physician Services
Madison, WI
12.2003 - 09.2012
- Determined whether other insurance was primary to Tricare by analyzing claims and eligibility details.
- Maintained patient and sponsor computer files, updating health insurance information for accurate case tracking.
- Responded to subrogation requests from attorneys and insurance companies with clear, timely correspondence.
- Addressed inquiries from the Judge Advocate General Offices while coordinating claim information and supporting documentation.
- Applied quick learning and strong organization to manage complex liability determinations and shifting insurance records.
Personal Banker/Customer Service
AnchorBank FSB
Madison, WI
09.1998 - 06.2012
- Identified customer financial needs and matched products and services to immediate and future goals.
- Built professional customer relationships through consistent service excellence and responsive follow-up.
- Applied bank policies and procedures while serving as senior customer service associate and backup safe deposit box attendant.
Environmental Analyst
Hazelton Environmental Services
Madison, WI
06.1992 - 03.1997
- Responded to client inquiries and supported account executives with project coordination and client management.
- Tracked sample status and followed up on pending work to keep clients informed.
- Prepared and mailed reports after verifying pre-processing, invoices, and quotations for accuracy.
- Completed weekly quality assurance audits on final laboratory reports to confirm reporting accuracy.
- Verified documentation before release, reducing errors across invoices, quotations, and final reports.
Education
Bachelor of Science - Biology
DePaul University
Chicago, IL12-1988
Skills
- Denial management
- Appeals processing
- Payer follow-up
- Claims reprocessing
- Coverage verification
- Eligibility determination
- Benefit verification
- Authorization review
- Account documentation
- Epic professional billing
Timeline
Revenue Cycle, Patient Financial Services Representative II/Government Team
Exact Sciences Corporation
11.2021 - Current
Medicare Insurance Follow Up Specialist
SSM Health/Dean Medical Group
08.2012 - 11.2021
Third Party Liability Processor
Wisconsin Physician Services
12.2003 - 09.2012
Personal Banker/Customer Service
AnchorBank FSB
09.1998 - 06.2012
Environmental Analyst
Hazelton Environmental Services
06.1992 - 03.1997
Bachelor of Science - Biology
DePaul University