Mercedes Sheffield
Tier 2 Claims & Records Associate (Remote)
York,AL
Summary
Meticulous and knowledgeable healthcare administration professional with over five years of experience in appeals processing, claims adjudication, and patient service coordination. Demonstrated expertise in analyzing medical documentation, managing benefit disputes, and maintaining compliance with CMS, HIPAA, and ERISA guidelines. Proven ability to lead teams, implement operational improvements, and deliver exceptional outcomes in both on-site and remote environments.
Overview
6
6
years of professional experience
2021
2021
years of post-secondary education
2
2
Certifications
1
1
Language
Work History
Tier 2 Claims & Records Associate (Remote)
Reliant Benefit Solutions
04.2022 - Current
- Conduct complex appeals reviews involving denied claims and benefit disputes.
- Draft detailed determination letters referencing plan policies and clinical criteria.
- Coordinate with healthcare providers, claims processors, and compliance analysts to resolve appeal cases.
- Lead quarterly audit reviews and support training initiatives for new appeals team members.
- Ensure all appeals are resolved within regulatory timeframes and documented per protocol.
- Assisted in the development of a comprehensive records retention schedule, aligning with legal requirements and organizational needs.
- Contributed to improved compliance by assisting in developing policies addressing privacy concerns related to records management.
- Managed multiple competing priorities effectively, ensuring high-quality work while meeting deadlines consistently within a fast-paced environment.
Claims Processing Specialist (Remote)
Horizon Managed Care Services
06.2020 - 03.2022
- Processed and adjudicated insurance claims for inpatient and outpatient services.
- Interpreted benefit plan language, determined coverage eligibility, and applied cost-containment measures.
- Liaised with patient representatives and medical review teams to resolve escalated claim issues.
- Conducted rework assessments and identified patterns contributing to underpayment or denial trends.
- Collaborated with the training department to standardize adjudication procedures.
Medical Assistant
Hill Hospital of Sumter County
02.2019 - 05.2020
- Performed routine clinical tasks including vitals, patient intake, and EMR documentation under physician supervision.
- Supported front office functions such as scheduling, referrals, and benefit verification.
- Assisted in patient education and preparation for procedures.
- Complied with infection control standards and maintained HIPAA-compliant documentation.
- Contributed to efficient clinic flow by balancing administrative and clinical responsibilities.
Education
Associate of Applied Science - Health Information Management
Wallace State Community College
Hanceville, ALSkills
- Claims Appeals & Dispute Resolution
- Eligibility Verification & Prior Authorization
- Regulatory Compliance (HIPAA, CMS, ERISA)
- EHR Systems
- DG Claims Software
Professional References
- Jasmine Carter, Team Lead, Reliant Benefit Solutions, jasmine.carter@reliantbenefits.org, (205) 499-4227
- Michael Thompson, Supervisor, Horizon Managed Care Services, michael.thompson@horizonmcs.com, (205) 499-3388
- Teresa Walker, Charge Nurse, Hill Hospital of Sumter County, teresa.walker@hillhospitalsc.org, (205) 499-0378
Accomplishments
I am a dedicated and compassionate professional who takes pride in delivering exceptional service in every role I undertake. With a strong work ethic and a genuine commitment to helping others, I approach each task with care, precision, and a deep sense of responsibility. I thrive in fast-paced environments, consistently showing up as reliable, focused, and eager to contribute to the success of my team and the well-being of those I serve.
Certification
Certfied Medical Assistant
Timeline
Tier 2 Claims & Records Associate (Remote)
Reliant Benefit Solutions
04.2022 - Current
Claims Processing Specialist (Remote)
Horizon Managed Care Services
06.2020 - 03.2022
Medical Assistant
Hill Hospital of Sumter County
02.2019 - 05.2020
Associate of Applied Science - Health Information Management
Wallace State Community College
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