Shakeema Thom
Brooklyn
Summary
Trustworthy and ethical experienced managed care professional with over 10 years of industry experience. Analytical, fast learner, and thrives in a fast-paced environment. Skilled in claim adjudication, investigating instances of healthcare fraud/abuse, and appeals filed by members and providers.
Investigative professional with keen eye for detail and commitment to uncovering fraud and misconduct. Proven ability to manage intricate cases and ensure adherence to legal standards. Known for fostering teamwork and adapting to evolving investigative needs, utilizing advanced research and critical thinking skills.
Overview
13
13
years of professional experience
1
1
Certification
Work History
APPEALS ANALYST
HORIZON BLUE CROSS BLUE SHIELD
09.2022 - Current
- Assess cause(s) of complaint/appeal, conducts thorough research of issue(s), determines required course of action and final disposition.
- Interacts with relevant parties to facilitate timely and accurate complaint/appeal resolution.
- Authorize administrative exceptions which may involve claim adjustment resulting in payments at higher threshold levels to bring closure to the complaint/appeal.
- Responds to regulatory entity or members/providers, both verbally and in writing, regarding issue details and final determination made by Horizon to close the complaint/appeal.
- Prepare materials for and attend case study meetings facilitated by designated internal or external parties.
- Document, prepare, and present upheld appeal cases to our internal Law Committee for submission to the Independent Review Entity (IRE).
APPEALS AND GRIEVANCE SPECIALIST/SCREENER
GREENKEY RESOURCES
01.2022 - 06.2022
- Independently conduct thorough investigations of provider correspondence analyzing all the issues presented, apply appropriate policies and procedures, while collaborating with internal departments to resolve grievances.
- Provide written acknowledgment of provider correspondence, plan decisions and reconsideration outcomes.
- Ensure provider responses are completed within the applicable regulatory timeframes while identifying untimely submissions, and misrouted inquiries.
INVESTIGATOR/SENIOR INVESTIGATOR
HEALTHFIRST
01.2013 - 04.2021
- Document final resolutions referencing applicable policies and procedures to justify or deny payment.
- Identify and refer suspicious billing patterns related to provider complaints to the FWA department.
- Research and resolve instances of healthcare fraud and abuse referred by internal departments, hotline tips or appeals and grievance inquiries related to overcharging and disputed services.
- Collaborate with the analytics team, pharmacy and the SIU’s nurse coding advisor to identify irregular billing trends.
- Respond to law enforcement referrals and requests for information from the Office of Inspector General (OMIG) and department of health complaints within the regulatory timeframe.
- Managed incoming referrals for the Restricted Recipient Program and coordinated with claims to update restriction edits.
- Act as the department’s subject matter claims expert, training staff on recoupments while ensuring claims were processed based on the company’s policy and procedures.
- Identify and report claims system edits or processing errors to prevent overpayments.
- Collaborated with the claims reliability team to create policies and procedures for screening and identifying fraudulent out of country member reimbursement request.
- Conduct and document interviews (on telephone) for all parties involved in an investigation.
- Thoroughly researched allegations and developed detailed investigative memorandums including statements, documents, and exhibits for the fraud waste abuse committee.
- Made recommendations to place providers on prepay or initiate recoupments.
- Referred suspected fraud cases to law enforcement agencies.
- Document all relevant findings and case evidence in the company tracking system.
Education
Associates - Medical Administration
Monroe College
Bronx, NYSkills
- Medical terminology
- ICD-10, HCPCS, UB-04, DRG, CPT Codes
- Research and evidence collection skills
- Microsoft Office Word and Excel
- Case evaluation
- Policy interpretation
- Insurance policy knowledge
- Claims investigation
- Legal compliance
Certification
- AHFI- Accredited Health Care Fraud Investigator Certification
- AAPC National ICD-10 Training and Certificate
Timeline
APPEALS ANALYST
HORIZON BLUE CROSS BLUE SHIELD
09.2022 - Current
APPEALS AND GRIEVANCE SPECIALIST/SCREENER
GREENKEY RESOURCES
01.2022 - 06.2022
INVESTIGATOR/SENIOR INVESTIGATOR
HEALTHFIRST
01.2013 - 04.2021
Associates - Medical Administration
Monroe College