Summary
Overview
Work History
Education
Skills
Certification
Timeline
Generic

SHAINA STRAWDER

Margate

Summary

Innovative, customer-oriented insurance professional with 10+ years in the Healthcare Insurance Industry. Strong background in quality assurance, claims analysis, management principles, and practices. Committed to leveraging skillset to drive team success and contribute to organizational growth.


Overview

16
16
years of professional experience
1
1
Certification

Work History

HR- Leave of Absence Consultant

T-Mobile
02.2022 - Current
  • Managed company's USA western division leave program and polices.
  • Conducted risk assessments for business processes, recommending measures to mitigate potential impacts resulting in a 12% decrease in leave of absence litigation.
  • Analyzed STD, LTD and LOA data sets to identify trends and opportunities for process improvements within the organizations resulting a decreased of employee fraud, waste and abuse.
  • Delivered comprehensive LOA reports and training presentations to stakeholders, providing insights and actionable recommendations for business improvement.
  • Increased department satisfaction scores by developing comprehensive consulting strategies tailored to each business's unique challenges and objectives.


STD/LOA Case Manager

Aflac Inc.
04.2019 - 01.2022


  • Collaborated with senior management to create strategic policies and procedures to increase KPIs by 15%.
  • Achieved positive client outcomes by developing and implementing comprehensive case management plans.
  • Liaison between account holders and employees to resolve escalated and complex issues related to employment and regulatory compliance
  • Performed STD, FMLA, Statutory, and Leave claim management and audits on client accounts.
  • Performed complex case assessments for LTD transitioning.
  • Facilitated accommodations and transitional employee return to work plans.


Claims Examiner I, Absence Management

Matrix Absence Management Inc.
01.2016 - 04.2019
  • Served as subject matter expert on client accounts resulting in a 20% decrease in STD/FMLA and LOA claim processing and regulatory errors
  • Assisted with implementation and education of clients and employees on plan provisions
  • Responsible for the management, investigation, and decision-making of complex disability claims
  • Identified and resolved complex plan coverage, policies, and procedural problems
  • Performed STD payroll calculations and managed HR timekeeping database
  • Performed STD/FMLA claim audits and adjustments for quality assurance

STD/LOA Claims Manager

Aetna Inc
09.2012 - 07.2015
  • Managed three high profile employee benefit accounts
  • Maintained claim management audit score of 100%
  • Performed independent claim reviews on complex Disability, State Statutory, FMLA and LOA claims with exceptional accuracy
  • Investigated waste, abuse, and fraud
  • Calculated and adjusted claim payment errors
  • Educated and communicated with employees, employers, and physicians on claim processes, denials, and appeals
  • Documented claim decisions/actions with high attention to detail and entered data into appropriate claim processing systems
  • Mentored and trained new hires

Member Relations Subject Matter Expert (SME)

United Health Group
10.2010 - 09.2012
  • Performed claim and account audits to ensure quality standards
  • Supported and aided customer service representatives and members
  • Assisted with complex enrollment, disenrollment, and eligibility errors
  • Served as medical resource and consultant
  • Implemented and updated training material resources to comply with regulatory guidelines

Senior Customer Service Lead

United Health Group
01.2010 - 10.2010
  • Supported team of 20 employees and supervisor in call center environment
  • Resolved escalated provider and member issues on CMS plans
  • Reviewed claims to determine if medical evidence supports based on contractual provisions on Provider/Member Medicaid, Medicare and pharmacy claims
  • Assisted providers in obtaining all managed care paperwork for Pre-certification, authorization and referrals
  • Educated staff on state and federal statutes, rules, and regulations

Customer Service Representative

United Health Group
11.2008 - 01.2010
  • Effectively managed high-volume of inbound and outbound customer calls
  • Addressed and resolved customer product complaints empathetically and professionally
  • Referred unresolved customer grievances to designated departments for further investigation
  • Met or exceeded service and quality standards every review period

Education

Bachelor of Science - Health Administration

Florida Atlantic University
Boca Raton, FL

Skills

  • Warm, outgoing personality with the ability to interact effectively and in a supportive manner with persons of all ages and backgrounds
  • Effective communicator, self-starter with ability to adapt to change
  • Acute problem-solving, analytical and decision-making skills
  • Quality improvement, claim management, project implementation and project management competencies
  • Advance knowledge of Medicare, Medicaid, commercial, and private insurance plans
  • Advance knowledge of STD, FMLA, LOA, ADA and State Statutory plan policies and regulations
  • Medical terminology expert
  • Extensive computer knowledge of Microsoft suite programs, Salesforce, UKG,Kronos and Workday

Certification

DMEC California State Leave Law Certification

Timeline

HR- Leave of Absence Consultant

T-Mobile
02.2022 - Current

STD/LOA Case Manager

Aflac Inc.
04.2019 - 01.2022

Claims Examiner I, Absence Management

Matrix Absence Management Inc.
01.2016 - 04.2019

STD/LOA Claims Manager

Aetna Inc
09.2012 - 07.2015

Member Relations Subject Matter Expert (SME)

United Health Group
10.2010 - 09.2012

Senior Customer Service Lead

United Health Group
01.2010 - 10.2010

Customer Service Representative

United Health Group
11.2008 - 01.2010

Bachelor of Science - Health Administration

Florida Atlantic University

Similar Profiles

CREATE PROFILE
SHAINA STRAWDER