Shameca Hines
Charlotte,NC
Summary
Talented Case Manager adept at handling high caseloads without sacrificing quality of care. Operates in high-pressure environments while recommending best resources and courses of action to benefit patient needs and return each to optimal quality of life.
Overview
24
24
years of professional experience
1
1
Certification
Work History
Case Manager
PRO-Spectus
02.2023 - Current
- Coordinates with field pharmaceutical sales team to address patient payer issues.
- Analyzes patient medical documentation to ensure it meets medical policy criteria.
- Address specialty pharmacy and buy and bill reimbursement issues.
- Coordinates with physician offices and facilities to address prior authorizations and reimbursement concerns.
- Developed and implemented comprehensive case management plans to address client needs and goals.
Reimbursement Specialist
PRO-Spectus
12.2020 - 03.2023
- Assisted with insurance appeals process for claims and prior authorizations.
- Coordinated with insurance providers to verify customer's policy benefits in relation to claims.
- Followed up on denied and unpaid claims to resolve problems and obtain payments.
- Employed clinical and billing codes expertise to correct billing inconsistencies.
- Prevented delays and claim denials by correcting information prior to submission.
- Delivered timely information to insurance representatives to resolve common and complex issues.
Patient Access Consultant
Lash Group
01.2019 - 12.2021
- Provided assistance to physician office staff and patients to complete and submit all necessary insurance forms and program applications
- Researched and resolves any claim denials or underpayment of claims
- Provided exceptional customer service to internal and external customers; resolves any customer requests in a timely and accurate manner; escalates complaints accordingly
- Reported any reimbursement trends/delays to supervisor (ie Billing denials, claim denials, pricing errors, payments, etc.)
- Communicated effectively to payors and/or claims clearinghouse to ensure accurate and timely electronically filed claims
- Worked on problems of moderate scope where analysis of data requires a review of a variety of factors
- Exercised judgment within defined standard operating procedures to determine appropriate action.
- Obtained patient's insurance information and determined eligibility for benefits for specific services rendered.
Insurance Coordinator
Carolinas HealthCare System
10.2012 - 01.2019
- Verified patient insurance for eligibility
- Submitted clinical notes for prior authorization when needed for outpatient surgery, MRI's, CT Scans and Workers Compensation patients
- Kept and updated detailed files with patient authorizations
- Keyed detailed notes on patient status as it relates to insurance deductibles, co-insurance and out of pocket maximums
- Calculated patient responsibility according to insurance and CPT Codes
- Analyzed discharge orders, clinical notes and corresponding CPT Codes for insurance approval
- Provided Customer Service to Patients on billing related matters.
Administrative Associate
Kelly Services
11.2011 - 10.2012
- (Temporary Assignment) Updates Vendor information in company database for Governmental Accounting Department
- Analyzed and verified Vendor information
- Analyzed outdated claims for possible closure.
Customer Care Specialist
Sprint Wireless
11.2008 - 10.2010
- Resolved Customer technical services and financial cell phone issues
- Sold merchandise and services
- Updated customer information
- Analyzed Customers current services to ensure customer satisfaction.
Underwriter/Claims Examiner/Customer Service Representative
GEICO Insurance Company
10.1999 - 10.2008
- Negotiated and settled insurance claims
- Coached and Supervised New Hires.
- Monitored New Hires customer interactions for Quality Assurance
- Reissued Canceled Polices
- Used underwriting guidelines to determine appropriate rates of insurance
- Provided Customer Service to Customers to resolve all underwriting and insurance matters
- Liaison between customers and the DMV to resolve customer license and registration issues
- Ran Monthly and Quarterly reports of claims closure ratio and appropriate use of reserved funds.
Education
Bachelor's - Business Leadership
Nyack College
Nyack, NY05.2011
Skills
- Public Speaking
- Problem solving
- Customer Service Skills
- Microsoft Excel
- Underwriting
- ICD-10
- Human Resources
- Medical Office Experience
- Workers' Compensation
- Insurance Verification
- Medical terminology
- Managed care
- Computer literacy
- Marketing
- Microsoft Word
- Microsoft Powerpoint
- Supervising experience
- Medicare
- Client Advocacy
Certification
Notary Public
Additional Information
- Works well without supervision
- Ability to prioritize and remain focused on the essence of an issue
- Excellent with customer support services
- Skilled at learning new concepts quickly while working well under pressure
Timeline
Case Manager
PRO-Spectus
02.2023 - Current
Reimbursement Specialist
PRO-Spectus
12.2020 - 03.2023
Patient Access Consultant
Lash Group
01.2019 - 12.2021
Insurance Coordinator
Carolinas HealthCare System
10.2012 - 01.2019
Administrative Associate
Kelly Services
11.2011 - 10.2012
Customer Care Specialist
Sprint Wireless
11.2008 - 10.2010
Underwriter/Claims Examiner/Customer Service Representative
GEICO Insurance Company
10.1999 - 10.2008
Bachelor's - Business Leadership
Nyack College