Shambra D. Petway
Reporting Analyst/ Leadership
Nashville,TN
Summary
Accomplished Consultant drives organizational improvements through leveraging expertise in research and system enhancement. Well-versed in collaborating with employees and leaders to resolve control and procedural problems negatively affecting business operations. Dedicated to cost, process and resource optimization. Experienced in Office Management, Quality Analyst, Customer Service Supervisor, Reporting Specialist, Billing Coordinator, and Project Management. Result oriented professional with a varied background serving as vital linkage between support services and clients. Superior Customer Service Leader, and keen Analytical Coding Skills in ICD-10, CPT, and HCPCS. Exceptional organizational skills coupled with extraordinary communication ability resulting in consistent client satisfaction. Excellent Microsoft Office skills, Collections, Facets, Macess, WinSCP, OnBase,SharePoint/ Care Compass, and HealthStar, TEDS, and Service Now.
Overview
21
21
years of professional experience
16
16
years of post-secondary education
Work History
Reporting Specialist
CGS, Blue Cross Blue Shield
Nashville, TN
06.2020 - Current
- Review change requests and/or other process changes that impact area reports in TDL/CRT for CMS (Center for Medicaid and Medicare Services
- Retrieve data from area systems to create a variety of reporting for J15 MSRE, MSR, FY22 Savings, BI-Annual ADR, HOPD PA (Prior Authorizations) Metrics, Monthly MR Resumption Reports, Monthly Radiology Report
- Retrieve data from MRAC-Medical Claims &Record Review for Award Fee Claims, PO, RES/TR Claims and create file folders for Part A,B and HHH
- Upload necessary documentation using WinSCP to Religroup for audit
- Operate as PO (Point of Contact) for CGS for reporting and sending necessary report for uploading to ART for PMO to CMS(Centers of Medicare and Medicaid Services
- Analyze J15 CGS Weekly TDL-220068(Education Report), and Monthly MCCM report Part HHH before sending to CMS
- Ensure appropriate updates are made to report templates to reflect any changes received
- Perform testing of reports to ensure changes made produce expected results and documented all changes that were made.
- Exported and converted raw data from various databases and applications to extrapolate data into usable reports.
- Analyze current reporting templates to identify opportunities for improvement in efficiency and accuracy
- Review and research accuracy of data on reports
- Correct or coordinate the correction of any discrepancies found within the report output and ensure all corrections have been made before forwarding to the appropriate area.
- Process morning Prior Authorization Report for Part A utilizing OnBase to retrieve data.
- Supported cross-functional relationships to discuss and seek resolution to issues discovered during analysis of various reports and data.
CHIP Program
Technosoft Corporation, Deloitte Consulting, TennCare State of Tennessee
Southfield, Michigan
08.2018 - 06.2019
- Responsible for troubleshooting Self-Service Tickets for TennCare TEDS online application system for the State through Service Now
- Provides answers to clients by identifying problems; researching answers; guiding client through corrective steps in a timely manner to service issues and requests for members
- Provides information regarding network providers or general program information when requested
- Perform Special Projects but not limited to daily reports, and provide other functions as needed
- Identify and resolve issues with FFM applications that is coming from the legacy data base to TEDS for Medicaid members
- Communicate with client via phone or via email once resolutions for service tickets are found as workarounds or permanent fixes.
LTSS, Management Lead /Reimbursement/Collections
Amerigroup Corp
Nashville, TN
01.2012 - 09.2018
- (Long Term Support Services) Utilization, Duties include creating authorizations and prior authorization in Facets and Milestones through Care Compass for members on Choices Medicaid Managed Care Program
- Periodically works with Manager to review individuals work accomplishments, discuss work problems/barriers, discuss progress in mastering tasks and work processes, and discusses individual training needs and career progression
- Create, schedule, and run reports, queries, and analyze data for claim errors or credentialing issues
- Analyzes and takes actions in resolving claims and support enrollment daily following established procedures and thresholds
- Enters detailed notes to update eRequest to provide details if the alert/edit cannot be resolved or must be rerouted to another responsible party for research/resolution
- Escalates and work escalated issues/alert/edit resolution as appropriate to minimize final billing delays
- Works with team members in billing, revenue integrity and/or the Medicare/Medicaid Service Center to resolve issues
- Conduct Utilization Management Review and Audits of Reports, conduct QA’s for team members’ performance
- Responsible for correcting/reimbursement for claim issues
- Assists the Coding Leads and/or Coding Managers in resolving unbilled reason codes (URC), and make out bound calls to providers for any necessary recoupments.
Grievance and Claims/Quality Analyst
Caremark Rx
Nashville, TN
01.2005 - 01.2012
- Provided effective customer care through superior customer service methods including problem solving and real time issue resolution maintaining a 98% quality average
- Handled high volume calls 90% of the day in fast paced high-energy call center environment and process grievances from Medicare D members
- Maintained patient profiles, prepare insurance claims, and explained Medicare D program to new enrollees and/or existing Tenncare or Medicare members
- Explain to member their rights when filing grievances and research their claims
- Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested
- Experience in working within a functional matrix organization
- Coached customer service representatives on live call performance and monitored reports for billing issues
- The ability to communicate clearly to people across departments and from various functional disciplines is required.
Customer Service Representative Supervisor
Sprint PCS
Nashville, TN
01.2000 - 01.2005
- Provided effective customer care through superior customer service methods including problem solving and real time issue resolution maintaining a 98- 100% quality average
- Generates monthly reports of audit findings, supports clients with issues identified and develops reports to assist management with information requested
- Overseen a team of 15-30 Reps daily
- Monitored live and recorded calls on each rep, ran daily reports for adherence and time
- Scheduled team meetings to discuss performance and the directions of the company
- Worked in ADP for recording hours and documenting FMLA, PTO and maintain scheduling requirements
- Follows guidelines for delinquent account management and collections
- Collect documentation to support account activity
- The ability to communicate clearly to people across departments and from various functional disciplines is required, any provide training for new hires
- Prepare and analyzed monthly and daily reports for operations
- Collaborated with other Managers for the success of building the company
- Ability to cross train on different aspect of customer service and research claims for refunding or collections.
Education
Bachelor of Science - Interdisciplinary Studies
Tennessee State University
Nashville, TN 01.2006 - Current
Skills
Database searches
undefinedWork Availability
monday
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Timeline
Reporting Specialist
CGS, Blue Cross Blue Shield
06.2020 - Current
CHIP Program
Technosoft Corporation, Deloitte Consulting, TennCare State of Tennessee
08.2018 - 06.2019
LTSS, Management Lead /Reimbursement/Collections
Amerigroup Corp
01.2012 - 09.2018
Bachelor of Science - Interdisciplinary Studies
Tennessee State University
01.2006 - Current
Grievance and Claims/Quality Analyst
Caremark Rx
01.2005 - 01.2012
Customer Service Representative Supervisor
Sprint PCS
01.2000 - 01.2005
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