Shala Jones

Professional Highlights

• 5 years of experience in medical claims management, claims operations, and team leadership.
• Expertise in complex medical claims, regulatory compliance, and healthcare reimbursement.
• Proven success leading and developing high-performing claims teams while improving productivity and quality.
• Strong knowledge of claims adjudication, appeals, provider relations, and payment accuracy.
• Experienced in ensuring compliance with HIPAA, CMS guidelines, and payer policies.
• Skilled in process improvement, performance metrics, and reducing claim turnaround times.
• Collaborative leader with strong analytical, problem-solving, and stakeholder management skills.
• Proficient in claims management systems, data analysis, and Microsoft Office Suite.
• Communicated with policyholders to explain claims processes, coverage, and decisions.
• Managed workload effectively to ensure timely processing of claims within designated deadlines.
• Interpreted policy provisions to determine the extent of the company's liability.
• Analyzed claims data to determine coverage and liability, ensuring accurate.

• Obtained information from customer and communicated feedback for follow up when required to ensure solving to promote company operation in a more efficient manner.
• Analyzed customer information to prepare actionable product or service reports for management.
• Presented insurance rules, regulations, policy limitations, and policy changes to customers in an easy to understand manner.
• Resolved customer inquiries through effective communication and problem-solving skills.
• Collaborated with team members to improve customer service processes and workflows.

• Processed a high volume of claims efficiently while maintaining quality standards.
• Provided quality customer service to assigned, insured and claimants throughout claims process to deliver timely service to customers.
• Analyzed customer claims and determined coverage eligibility.
• Maintained up-to-date knowledge of insurance policies and regulatory changes.
• Educated customers on claim procedures and policy coverage options effectively.

• Gave appropriate action on incoming calls and emails to resolve billing and payment issues voiced by patients, guarantors and other third parties
• Resolved billing and payment issues through effective communication with patients, guarantors, and third parties via calls and emails
• Submitted required appeals to insurance companies to address claim issues
• Managed accounts receivable activities including billing, collections, payments processing.
• Reconciled discrepancies between accounts payable and receivable ledgers to identify any errors or omissions.
• Ensured timely payment of invoices as well as proper reconciliation of accounts payable and receivable records.