Nina Shaw
Glenn Heights,TX
Summary
Seasoned Claims Specialist with comprehensive background in insurance claim processing, policy interpretation, and dispute resolution. Have successfully managed high-volume claims environments, demonstrating keen ability to stay organized under pressure. Known for strong analytical skills, adept at reviewing documentation and validating coverage decisions. Consistently ensure prompt, fair settlements while maintaining compliance with industry regulations.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Claims Representative
RemX, McKesson Specialty
Dallas, TX
10.2024 - Current
- Reviewed denied claims for errors or omissions before finalizing decision notices.
- Reviewed prior authorization requests to ensure accuracy and completeness of required information.
- Assisted with developing policies and procedures related to prior authorizations.
- Performed detailed medical reviews of prior authorization request, following established criteria and protocols.
- Notified ordering providers of denied authorizations.
- Updated reference materials with Medicare, Medicaid and third-party payer requirements, guidelines, policies and list of accepted insurance plans.
Claims Specialist
Aetna, a CVS Health
Arlington, TX
10.2019 - 11.2023
- Reviewed denied claims for errors or omissions before finalizing decision notices.
- Handled modification and updating of policies.
- Monitored reports to identify claims issues and worked with adjusters to resolve problems.
- Examined claims, records and procedures to grant approval of coverage.
- Used insurance rate standards to calculate premiums, refunds, commissions and adjustments.
- Calculated benefit payments based on policy terms, coverage limits, and applicable regulations.
Medicare Specialist
Willis Tower Watson
Dallas, TX
05.2015 - 02.2019
- Drafted correspondence responding to inquiries about potential changes in patient eligibility for certain types of care covered by their plan.
- Granted, modified, denied, or terminated assistance based on key information and eligibility determination.
- Processed appeals submitted by customers regarding denied or reduced benefits under their Medicare plan.
- Compiled data into charts, graphs, and spreadsheets for analysis of current trends in the use of certain types of care covered by a patient's plan.
- Maintained confidential patient documentation to prevent data compromise and comply with HIPAA regulations.
- Resolved discrepancies related to payments made on behalf of customers according to approved guidelines set forth by CMS.
Customer Service/ Special Project- Email Team-Live Chat
Willis Towers Watson
10.2015 - 02.2017
- I took inbound calls from retirees from different clients.
- Assist with updating account information, and advising customers on their healthcare benefits.
- Assisted with their HRA accounts, funds, and reimbursement.
- Contact any insurance carriers they need to contact about benefits questions.
- Updated system with order specifics and customer details, preferences, and billing information.
Customer Service Analyst- Loan Modifications
Staff Mark -Bank of America
Westlake, TX
05.2013 - 04.2015
- Analyst was responsible for conducting loan reviews to ensure units are in compliance with all internal policy and procedures, federal, state, local and governmental regulatory requirements;
- Perform all duties in accordance with the company's policies and procedures, all US state and federal laws and regulations, where in the company operates
- Took inbound calls and process appeals for customers that receive decline letter for modifications, also updated customer info, explain to customer why their modifications are not approved, give status on appeals and research accounts for Customer Relationship Managers and give them status for their borrowers
Customer Service
Randstad- Pacifi Sales
07.2010 - 12.2012
- Took inbound calls and processed data entry for customer delivery info
- Made outbound calls to homeowners to advise of time frames of delivery, processed reschedules, damage allowances, and took escalated calls from customer that’s unsatisfied with time frames and product
- Communicate with home delivery dispatch team to process customers refusing product
Customer Service (Modifications)
Aerotech Staffing Services- Bank of America
07.2010 - 01.2012
- Took inbound calls and emailed homeowners documents as needed, advised homeowners the status of their modification loans, the process and timeframes, updated billing information and answered any questions homeowners had, also took mortgage payments via check, also communicated with underwriters
Customer Service
TXU Energy
Irving, TX
02.2009 - 07.2009
- Responsible for setting up new accounts on business customers, administrated system functions on all opening, closing, and balance procedures to according finance guidelines, updated billing information, edited accounts, and took service calls, setup reconnect orders for customers without service, took payments via check and credit card, canceled electricity for non-payments, set up payment arrangements
Customer Service
Synectic Staffing- AT&T
Dallas, TX
11.2007 - 02.2009
- Responsible for improving customer retention through programs and service provided to customers
- Set up new accounts related to telephone, cable, and internet services explained billing procedures, updated account info, and advised of new plans, answered customer/client request or inquiries concerning products, equipment claims, and reports problem areas
- Made recommendations according systems to process of AT&T products and service
Customer Service
Alliance Data System
Dallas, TX
02.2006 - 03.2007
- Set up new accounts for utilities services, offered solutions on bringing accounts current, set up payments plans, service orders, and extensions and updated billing info
Customer Service Supervisor
Best Buy
Dallas, TX
07.2001 - 11.2005
- Created a positive customer experience for all best buy customers, originated credit cards for qualifying customers, and supervised over 20 employees in customer service dept
- Made sure all new employees went through training and knew duties of job responsibility
- Set up orientations, interviews and training dates, processed admin paper work, deposits, and closed store
- Took weekly conference calls
Education
High School Diploma -
South Oak Cliff High School
Dallas, TX04-2000
Some College (No Degree) - Allied Health
Navarro College
Midlothian, TXSkills
- Documentation research
- Allocating claims
- Coverage assessments
- Decision-making
- Claims trend analysis
- Coverage determination
- Insurance claims review
- Claims investigation
References
References upon Request
Certification
- RDA
- Certified Phlebotomis
Timeline
Claims Representative
RemX, McKesson Specialty
10.2024 - Current
Claims Specialist
Aetna, a CVS Health
10.2019 - 11.2023
Customer Service/ Special Project- Email Team-Live Chat
Willis Towers Watson
10.2015 - 02.2017
Medicare Specialist
Willis Tower Watson
05.2015 - 02.2019
Customer Service Analyst- Loan Modifications
Staff Mark -Bank of America
05.2013 - 04.2015
Customer Service
Randstad- Pacifi Sales
07.2010 - 12.2012
Customer Service (Modifications)
Aerotech Staffing Services- Bank of America
07.2010 - 01.2012
Customer Service
TXU Energy
02.2009 - 07.2009
Customer Service
Synectic Staffing- AT&T
11.2007 - 02.2009
Customer Service
Alliance Data System
02.2006 - 03.2007
Customer Service Supervisor
Best Buy
07.2001 - 11.2005
- RDA
- Certified Phlebotomis
High School Diploma -
South Oak Cliff High School
Some College (No Degree) - Allied Health
Navarro College
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