MONIQUE SHEPPERSON
CHESTER
Summary
Seasoned Senior Claims Analyst with wide-ranging experience in managing and executing complex claims processes. Possess strong analytical skills, adept at interpreting policy language and determining coverage. Proven track record of effectively communicating claim resolutions to stakeholders while adhering to regulatory compliance protocols. Demonstrated ability to improve efficiency and accuracy in claims processing and settlement procedures.
Overview
18
18
years of professional experience
16
16
years of post-secondary education
Work History
Senior Claims Analyst
AvMed
Chester
01.2021 - Current
- Analyzed complex claims to ensure compliance with policies and regulations.
- Collaborated with cross-functional teams to resolve escalated claims issues.
- Reviewed and interpreted policy documents for accurate claims processing.
- Advised management on trends impacting claims processing efficiency and accuracy.
- Managed vendor relations to streamline claim resolution processes effectively.
- Performed administrative tasks such as filing paperwork, responding to emails and calls.
- Maintained accurate records of all claims activities for audit purposes.
- Interpreted insurance policies, endorsements and riders to identify coverage limits and exclusions.
- Reviewed, researched and evaluated customer claims to determine coverage under policy provisions or applicable laws.
- Monitored performance metrics such as cycle time, customer service ratings, loss ratios for effective decision making.
RETIREE HEALTH PLAN ADMINISTRATOR
Virginia Housing
Glen Allen
08.2020 - 02.2023
- Managed the daily operations of retiree health benefits, ensuring compliance with policy guidelines and prompt service delivery.
- Conducted thorough analysis of claims, accounts receivable, and accounts payable using Tableau to maintain accurate financial records.
- Evaluated and processed reimbursement claims, verifying that each submission met IRS requirements and maintaining detailed documentation.
CARE COORDINATOR/ WORKER SUPERVISOR- NON-CLINICAL
Magellan Complete Care of Virginia
Glen Allen
07.2015 - 08.2020
- Coordinated care by managing the prior authorization process and liaising with healthcare providers to obtain necessary medical records, ensuring timely delivery of services.
- Lead claims team, ensuring compliance and quality, driving measurable service improvements.
- Conduct audits to enhance coding accuracy, elevating documentation standards.
- Oversee team performance and report to leadership, resolving client issues efficiently.
- Enhance staff development through strategic hiring and career planning initiatives.
- Utilize analytics for trend analysis, boosting service delivery effectiveness.
- Oversaw team performance metrics, delivering comprehensive reports that informed strategic decisions and improved operational efficiency.
- Coordinated cross-functional efforts to resolve complex client issues, strengthening relationships and enhancing client satisfaction ratings.
- Managed an operational team dedicated to healthcare payer claims, ensuring adherence to processes and maintaining high service quality.
- Fostered staff development through targeted training and mentorship, cultivating a motivated team committed to excellence.
- Led a claims team to enhance compliance and quality, achieving measurable service improvements and increasing operational efficiency.
- Conducted detailed audits to improve coding accuracy, resulting in elevated documentation standards and reduced claim processing errors.
- Communicated effectively with retirees regarding the status of their claims, providing clear instructions for additional documentation when necessary.
- Streamlined retiree health benefits operations, enhancing service delivery speed and ensuring 100% compliance with policy guidelines.
- Utilized Tableau for in-depth analysis of financial records, leading to substantial improvements in claims accuracy and processing efficiency.
- Fostered strong communication with retirees, clarifying claim statuses and ensuring timely submission of necessary documentation.
- Maintained comprehensive records of reimbursement claims, verifying compliance with IRS standards to uphold financial integrity.
- Provided empathetic support to retirees navigating the claims process, enhancing their experience and building trust in the system.
BILLING AND CLAIMS SUPERVISOR
Pediatrix
Glen Allen
08.2010 - 07.2018
- Managed the medical billing operations, ensuring compliance with third-party requirements and regulatory guidelines at federal, state, and local levels.
- Utilized Tableau to generate daily and weekly reports, and employed Epic for claim status monitoring and team coordination.
- Conducted thorough investigations of electronic claims submission errors and collaborated with various departments to resolve issues.
CLAIMS PROCESSOR/ PROVIDER AND MEMBER SERVICES QUALITY MANAGER
General Dynamics
Chester
08.2007 - 07.2010
- Reviewed and processed Medicare and Dual Enrollment claims, ensuring adherence to state Medicaid eligibility criteria and timely resolution of beneficiary inquiries.
- Delivered constructive feedback to customer service representatives, enhancing overall performance and service quality in addressing beneficiary issues, including claims and enrollment processes.
- Contributed to team development by mentoring new staff, leading training initiatives, and staying abreast of evolving industry information to maintain accuracy in member and provider interactions.
- Fostered a collaborative environment by mentoring new staff, enhancing team cohesion and improving overall service delivery.
- Streamlined the prior authorization process, significantly reducing delays and ensuring timely access to necessary medical services.
- Analyzed utilization trends to improve case management workflows, leading to more efficient resource allocation and enhanced patient outcomes.
- Implemented a tracking system for care transitions, facilitating smoother member access to community resources and improving continuity of care.
- Maintained accurate documentation of member interactions and care plans, ensuring compliance with industry standards and enhancing service quality.
- Orchestrated care coordination efforts to ensure timely access to medical services, enhancing patient satisfaction and expediting treatment timelines.
- Maintained accurate patient information through verification processes and provided support across Front-End Department functions.
- Streamlined billing processes to enhance accuracy, resulting in a reduction of claim denials and improved revenue cycle efficiency.
- Analyzed claim trends to identify recurring issues, implementing corrective measures that led to noticeable gains in approval rates.
- Developed training programs for staff on billing software, enhancing team proficiency and ensuring compliance with evolving regulations.
- Fostered partnerships with healthcare providers to clarify billing inquiries, strengthening relationships and improving patient satisfaction.
- Provided mentorship to junior staff, cultivating a supportive environment that encouraged professional growth and teamwork.
- Streamlined billing processes, enhancing accuracy and reducing claim denials, which significantly improved the revenue cycle efficiency.
- Maintained strict compliance with HIPAA regulations while communicating claim statuses and documentation requirements to providers and beneficiaries.
- Evaluated Medicare claims for accuracy, ensuring expedited processing and compliance with state regulations, leading to fewer disputes and improved beneficiary satisfaction.
- Implemented training programs for customer service teams, which enhanced service quality and significantly reduced resolution times for beneficiary inquiries.
- Conducted thorough audits of claims documentation, maintaining adherence to HIPAA standards and ensuring confidentiality while improving operational efficiency.
- Facilitated cross-departmental meetings to streamline communication between claims and customer service, fostering a unified approach to problem-solving and enhancing overall service delivery.
- Provided mentorship to team members, promoting a culture of continuous improvement and collaboration, which strengthened team dynamics and morale.
- Streamlined claims processing workflows, achieving noticeable gains in efficiency and reducing resolution times for beneficiary inquiries.
Education
BACHELOR'S DEGREE - HEALTH SCIENCES
South University
Richmond, Virginia 01.2010 - 08.2025
Skills
- Claims Processing
- Healthcare Operations
- Agile
- Salesforce
- Tableau
- Epic
- Health Payer Rules software
- Medical Billing
- HIPAA
- CPT
- ICD-10
- MS Suite
- Customer Service
- Appeals
- Data analysis
- Claims processing
- Policy interpretation
Timeline
Senior Claims Analyst
AvMed
01.2021 - Current
RETIREE HEALTH PLAN ADMINISTRATOR
Virginia Housing
08.2020 - 02.2023
CARE COORDINATOR/ WORKER SUPERVISOR- NON-CLINICAL
Magellan Complete Care of Virginia
07.2015 - 08.2020
BILLING AND CLAIMS SUPERVISOR
Pediatrix
08.2010 - 07.2018
BACHELOR'S DEGREE - HEALTH SCIENCES
South University
01.2010 - 08.2025
CLAIMS PROCESSOR/ PROVIDER AND MEMBER SERVICES QUALITY MANAGER
General Dynamics
08.2007 - 07.2010
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